Anatomy - hand and wrist Flashcards
(133 cards)
1
Q
Describe the blood supply to the scaphoid? What is the main supply?
A
Dorsal carpal branch of the radial artery is the main - supplies 80% Also: Superficial palmar branch of the radial artery
2
Q
Which ligament is violated and must be repaired in the volar approach to the scaphoid?
A
Radioscaphocapitate ligament
3
Q
Which ligament is the strongest ligament that resists perilunate dislocations in the wrist?
A
Long radiolunate ligament
4
Q
What is the weakest point in the volar wrist?
A
Space of Poirier
5
Q
What is the significance of the Space of Poirier?
A
It is the weakest point in the volar wrist and is where volar lunate dislocations occur most often.
6
Q
Where is the Space of Poirier located?
A
Volar wrist at the junction of the Lunate and Trapezium/TrapezoidBordered by the Radiocapitate & Radiolunotriquetral ligaments (aka long radiolunate)
7
Q
What “ligament” in the wrist is actually a neurovascular bundle?
A
Radioscapholunate ligament
8
Q
What are the components of the radioscapholunate ligament?
A
Vascular branches of the anterior interosseous and radial arteriesNerve branches of the anterior interosseous nerve
9
Q
Where is the radioscapholunate ligament found?
A
Between the long and short radiolunate ligaments, piercing the joint capsule
10
Q
What are the components of the TFCC?
A
Triangular fibrocartilage disc (articular disc)Meniscus homolog (disc-carpal ligaments)Volar Ulnocarpal ligaments (ulnolunate & ulnotriquetral)Dorsal and volar Radioulnar ligaments (palmar & dorsal, each with a superficial & deep component)ECU subsheath
11
Q
What is the ligament of Testut?
A
Radioscapholunate ligament. Actually a neurovascular bundle with no contribution to carpal stability
12
Q
What are the contents of the anatomical snuffbox?
A
Radial arterySensory branch of the radial nerveWrist joint capsuleFat
13
Q
What are the borders of the anatomical snuffbox?
A
Trianglr: Anterior: EPB, ABL Posterior: EPL (extensor compartments 1&3)Base: radial stylus processFloor: scaphoid & trapezium
14
Q
What are the stabilizers of the DRUJ?
A
Extrinsic:ECU tendon & SubsheathPronator quadratusInterosseous membraneJoint capsuleTFCCIntrinsic:Bony contactSuperficial radioulnar ligaments - origina at ulnar styloidDeep radioulnar ligaments (ligamentum subcruentum) origin at fovea
15
Q
What are the components of the scapholunate ligament?
A
Dorsal (strongest)PalmarProximal (thin, membranous)
16
Q
What is a lesser arc injury?
A
Purely ligamentous perilunate injury
17
Q
What is a greater arc injury?
A
Fracture around the lunate - scaphoid, capitate, hamate, triquetrum
18
Q
What are the extrinsic ligaments of the dorsal wrist?
A
Dorsal radiocarpal ligamentsDorsal intercarpal ligaments
19
Q
What is Kienbock’s disease?
A
Avascular necrosis of the lunate.
20
Q
Why do perilunate dislocations usually NOT end up in AVN?
A
Because it has a rich blood supply including:Dorsal and volar radial branchesBranches of the dorsal and volar intercarpal arch Anterior interosseous artery
21
Q
How many articulations does the scaphoid have?
A
5 Radius, capitate, lunate, trapezoid, trapezium
22
Q
What is intersection syndrome?
A
Overuse condition affecting the seconddorsal compartment - ECRL and ECRB
23
Q
What is DeQuervain’s tenosynovitis?
A
Inflammation of the tenosynovium of the abductor pollicis longus and extensor pollicis brevis tendonsAffects 1st dorsal compartmentDiagnosed with Finklestein’s test - Increase in pain when the thumb is held in palm and wrist is ulnarly deviated - Pain is over the radial side of the wrist (1st dorsal compartment)
24
Q
What is Wartenberg’s Syndrome
A
Radial neuritis- Neuritis of the superficial branch of the radial nerve- Inflammation due to stretch, compression or direct blow- Compression occurs between the brachioradialis and ECRL
25
Describe Eaton's classification of the radiographic stages of thumb CMC OA
1: Normal2: Joint spacer narrowing, osteophytes 2mm3: Joint space narrowing, osteophytes >2mm4: pantrapezial arthritis
26
What is the bony articulation of the distal radioulnar joint?
Sigmoid notch of the radius articulation with the ulnai.e. "lesser" sigmoid notch
27
What are the stabilizers of the distal radio-ulnar joint (DRUJ)?
- Bony integrity between sigmoid notch of the radius and ulna- Interosseous membrane- TFCC- Joint capsule- Pronator quadratus- Extensor carpi ulnaris
28
What are the muscular attachments of the proximal row of the carpal bones?
None
29
What carpal bones do not contribute to carpal motion?
Pisiform: it's a sesamoid bone of the flexor carpi ulnaris
30
The Pisiform is a sesamoid bone for what tendon?
Flexor carpi ulnaris (FCU)
31
What are the contents of the carpal tunnel?
9 flexor tendons:- 4 for flexor digitorum superficialis- 4 for flexor digitorum profundus- Flexor pollicis longusMedian nerve
32
What are the borders of the carpal tunnel?
Radially: scaphoid & TrapeziumUlnar: Pisiform & hamateRoof: flexor retinaculum/transverse carpal ligamentFloor: proximal carpal row & radiocarpal ligaments
33
During carpal tunnel release, what nerve is most at risk when cutting the transverse carpal ligament? How do you avoid it?
Recurrent motor branch of the median nerveAvoid it by making your cut as ulnar as possible- Ulnar side of the 4th digit when flexed to the palm
34
What are the borders of Guyon's Canal?
Roof: volar carpal ligamentFloor: Transverse carpal ligament & hypothenar usclesRadial: Hook of hamateUlnar: Pisiform, pisohamate ligament, abductor digiti minimi muscle belly
35
How is Guyon's Canal divided? What is the pathology of damaging each division?
3 zones:Zone 1: proximal to the bifurcation of the ulnar nerve - Causes mixed motor and sensory symptomsZone 2: surrounds deep motor branch of the ulnar nerve - It is more radial - Causes only motor symptomsZone 3: Surrounds superficial sensory branch of the ulnar nerve - It is more ulnar - Causes only sensory symptoms
36
what is the major contributor to the superficial palmar arch?
Ulnar artery- Radial has minor contributions
37
What is the major contributor to the deep and superficial palmar arches?
Radial artery: deepulnar artery: superficial
38
What muscles attach to the scaphoid>?
None
39
How much of the scaphoid is covered in articular cartilage?
70%
40
name the intrinsic hand muscles of the thenar eminence and their function:
Abductor pollicis brevis- Abducts thumb at CMC & MCPFlexor pollicis brevis- Flexes thumb at CMC & MCPOpponens pollicis- Opposition of thumb
41
What is the innervation of flexor pollicis brevis?
Dual innervation- Superficial: median- Deep: ulnar
42
What are the intrinsic hand muscles of the hypothenar eminence and their actions?
Abductor digiti minimi brevis- Abducts 5th digit at MCPFlexor digiti minimi- Flexes 5th digit at MCPOpponens digiti minimi- Opposition of 5th digit
43
Name the intrinsic hand muscles of the hypothenar eminence and their nervous innervation
Abductor digiti minimiFlexor digiti mimini brevisOpponens digiti minimi- All innervated by ulnar nerve
44
Name the intrinsic muscles of the thenar eminence and their nervous innervation:
Abductor pollicis brevis- Median nerveFlexor pollicis brevis - Dual innevation- Superficial: median nerve- Deep: ulnar nerveOpponens pollicis- Median nerve
45
What are the muscles of the hand innervated by the median nerve?
LOAF- Lumbricals (radial 2 aka 1 & 2)- Opponens pollicis- Abductor pollicis brevis- Flexor pollicis brevis - note this has dual innervation - Superficial: median - Deep: ulnar
46
What is the only muscle to originate and insert onto a tendon? Which tendons does it originate and insert into?
Lumbricals- Originate from tendons of flexor digitorum profundus- Insert into extensor expansion on dorsal aspect of each digit's radial side
47
What is the function of the dorsal and palmar interossei?
Dorsal: Abduct the fingers Palmar: Adduct the fingers - Remember DAB and PAD
48
What is the OINA of the palmar interossei?
O: They originate on the side facing the long finger1st: ulnar side of 2nd MC2nd: radial side of 4th MC3rd: radial side of 5th MCI: Extensor expansion of 2,4,5 digitsN: ulnarA: adduction of 1,2,4,5th digitsnb: adduction/abduction is named relative to long finger
49
What is the OINA of the dorsal interossei?
O:1st medial head: radial side of 2nd MC1st lateral head: ulnar side of 1st MC2nd, 3rd, 4th: space between the MC bonesI:1st: radial sid of 2nd proximal phalanx2nd: radial side of 3rd PP3rd: ulnar side of 3rd PP4th ulnar side of 4th PPN: ulnarA: ABduction of 2,3,5 fingers (away from midline)
50
What are the O, I, N, A of the lumbricals?
O: tendons of flexor digitorum profundusI: extensor expansion on dorsal aspect of each digit's radial sideN: 1/2: median, 3/4: ulnarA: flexion of MCP of digist 2-5 - Extension of DIP & PIP of digits 2-5
51
What is the OINA of the palmaris brevis?
O: Flexor retinaculumI: Palmar surface of skin on ulnar side of handN: UlnarA: Wrinkles skin on ulnar side of hand
52
Describe the safe position of the hand. Why is it safe?
Intrinsic plus position:- Wrist extended 10 deg- MCP Flexion to 70 deg- IP extendedIt's safe b/c with the MCPs in flexion, the collaterals are tight (at their longest)- So they will not get tight in a shortened position (short/lax in extension)
53
What are the components of the extensor hood?
Central tendonLateral BandsDorsal/palmar interosseiLumbricalsOblique retinacular ligamentsSagittal bandsWorks on both the MCP and IP joints
54
Describe the flexor zones of the hand?
1: Distal of FDS insertion (Jersey finger)2: DIP to distal palmar crease (no man's land)3: Palm (Assoc w/ neurovasc injury)4: Carpal tunnel (post-op adhesions)5: Wrist to forearm: (Assoc w/ neurovasc injury)Thumb: Early ROM NOT better, like other fingers- T1, T2, T3
55
Describe the pulley system of the fingers and thumb
Fingers:5 annular pulleys: - A1, A3, A5 at MCP, PIP, DIP - A2, A4 at proximal and distal phalanx. These are most important in preventing bowstringing3 cruciate pulleys - C1: at distal end of proximal phalanx - C2: at middle phalanx - C3: at distal end of middle phalanxThumb: A1 at MCP, A2 at IP Oblique between them at proximal phalanx
56
Where does the superficial branch of the radial nerve emerge from at the wrist?
Beneath brachioradialis 7-9cm proximal to rad styloid tip
57
What is the most common place for the palmar cutaneous branch of the median nerve to emerge? What is its location with respect to FCR and the carpal tunnel?
Ulnar to FCR- Travels outside the carpal tunnel, so not affected by CTS (you get sparing)
58
Space of Parona - where is it?
space between pron quadratus and flextor tendons - continuous with carpal tunnel and palmar space
59
Stener's lesion
Ulnar collateral ligament tear with interposed adductor pollicis tendon - prevents healing so is an indiation for surgical repairNormally, the UCL is deep to the adductor pollicis tendonA Stener lesion is characterised by slippage of the torn end of the ulnar collateral ligament superficial to the adductor aponeurosis / adductor pollicis muscleAKA the tendon/aponeurosis is now interposed between the ulnar collateral ligament and the MCP jointThis prevents healing and is an indication for surgical repair.
60
Froment's sign
Ulnar nerve injury
61
Wartenberg's sign
Ulnar nerve injury - Ulnar drift of small finger due to unopposed function of EDM (radial) with paralysis of palmar interossei (ulnar)EDM attaches ulnarly so will have an ulnar/abduction moment, pulling small finger ulnarlyvs: Wartenburg's syndrome: superficial radial nerve injury
62
Why is a flexor tendon sheath infection a medical emergency?
B/c the most common anatomical variants have flexor sheaths 1 & 5 communicating with the wrist/carpal tunnel, so infection can easily propagate up the wrist
63
What is the most common variation of the recurrent branch of the median nerve?
Extra ligamentous, distal to the carpal tunnel (46-95%)
64
What is the last muscle innervated by the median nerve proper?
Second lumbrical
65
Where does the dorsal branch of the ulnar nerve branch off?
5-12cm, average 9cm
66
What nerves branch off the ulnar nerve proximal to the elbow?
Usually none, but if any, are just articular branches
67
What is a Riche-Cannieu anastamosis?
Ulnar to median anastmosis in the hand. classically deep br of ulnar n to recurrent median. i.e. ulnar n supplying thenar muscles
68
Name the contents of the extensor compartments
1: ABL/EPB2: ECRB/ECRL3: EPL4: EDC/EIP (PIN)5: EDM6: ECU
69
Which is more distal, superficial or deep palmar arch?
Superficial - it is at the distal transverse palmar crease
70
Where is the superficial and deep palmar arches?
Superficial: distal transverse palmar crease Deep: Kaplan's cardinal line
71
Describe the extensor zones of the hand and wrist
Odd numbers are at the joints:I: DIPIII: PIPV: MCPVII: radiocarpalIX: forarm muscle belly
72
Name the contents of the extensor compartment of the wrist
I: APL/EPB2: ECRB/ECRL3: EPL4: EDC/EIP (PIN)5: EDM6: ECU
73
Name a syndrome or pathology for each extensor compartment of the wrist
1: De Quervain's tenosynovitis2: Intersection syndrome3: Drummer's wrist or traumatic rupture with DR #4: Extensor tenosynovitis5: Vaughn-Jackson' syndrome (common in RA06: Snapping ECU
74
Describe the flexor tenson injury zones:
Fingers:1: FDP to FDS insertion2: FDS to A1 pulley3: A1 pulley to carpal tunnel4: Carpal tunnel5: Tendons of forearm flexors6: Muscle bellies of forearm flexorsThumb:1: Distal to IP2: IP to A1 pulley3: thenar eminence4: carpal tunnel5: tendons of forearm flexors6: muscle bellies of forearm flexors
75
In what position is the radius shortest compared to the ulna (or the ulna longest compared to the radius)?
In pronationTHINK: supination is anatomic position so bones are uncrossed. In pronation, radius must cross over ulna, shortening it compared with the ulnaThat's why positive ulnar variance is mostly detected in pronation x-rays
76
What ligaments are the main restraint to subluxation of the DRUJ in supination and pronation?
Supination:Deep dorsal radioulnar ligament is the main restraint to dorsal subluxation of the radiusPronation:Deep volar radioulnar ligament is the main restraint to volar subluxation of the radius
77
Name the 9 palmar and 5 dorsal intrinsic carpal ligaments
see picture Palmar:scapholunatelunotriquetraltriquetrohamatetriquetrocapitatecapitohamatecapitotrapezoidaltrapeziotrapezoidalscaphotrapeziotrapezoidalscaphocapitate Dorsal:scapholunatelunotriquetraltrapeziotrapezoidalcapitotrapezoidalcapitohamate
78
What carpal bones do the following MC align with?1st MC2 MC3 MC4/5th MC
1st MC: Trapezium2nd MC: Trapezoid3rd MC: Capitate4th/5th MC: Hamate
79
Name the Volar extrensic Wrist ligaments (6)
RadioscaphocapitateRadioscapholunateLong radiolunateShort radioluateUlnolunateUlnotriquetral
80
What is the strongest wrist ligament?
Radioscaphocapitate**Note that the long radiolunate is the primary restraint to perilunate dislocations but not the strongest volar wrist ligament
81
What are the components of the scapholunate ligament?
Dorsal (strongest)PalmarMembranous (intraosseous, proximal)
82
Name the extrinsic dorsal wrist ligaments
Dorsal radiocarpalDorsal intercarpalThese converge on the triquetrum and can be used in the Mayo ligament sparing approaach that Gammon uses
83
What type of joints are the 1st - 5th CMC joints?
1st: saddle2-4: plane/synovial5th???
84
What are the components of the deep flexor retinaculum of the wrist?
Starts as: antebrachial fasciaBecomes: Transverse carpal ligamentBecomes Thenar & Hypothnar aponeurosis/Deep palmar fascia
85
What are the components of the superficial wrist retinaculum?
Carpal ligament and palmar ligament
86
What are the contents of the Guyon's canal?
Ulnar nerveUlnar artery
87
Name the bands affected & not affected by Dupuytren's Disease
Affected:PretendinousSpiralNatatoryLateralGrayson'sNot Affected:Trasnverse fibersCleland's ligaments(Some say only Cleland's is not affected)
88
What are the positions of Grayson's and Clelands Ligaments with respect to each other
Grayson's: (grip) are volar to the NV bundleCleland's (ceiling) are dorsal to the NV bundle
89
What are the variants of the flexor tendon sheath anatomy?Why is this important?
Communication between 1st, 5th flexors (most common)Communication between 1st, 2nd, 5th flexorsNo communication between 1st and anywhere elseCan get horseshoe abscesses if there is communication between the 2st/5th digists
90
Name the potential spaces in the hand (3) and forearm (1)
Hand:Midpalmar spaceThenar spaceHypothenar spaceForearm:Parona's space
91
Describe Parona's Space
Potential space superficial to pronator quadratusContiguous with the midpalmar and thenar spaces (also potnetial spaces)
92
Name the intrinsic hand muscles of the thenar eminence:
Abductor pollicis brevisFlexor pollicis brevisOpponens pollicisAdductor pollicis
93
Name the intrinsic hand muscles of the hypothenar eminence:
Abductor digiti minimiFlexor digiti minimiOpponens digiti minimi
94
Name the OINA of Abductor Pollicis Brevis
O: Scaphoid tuberosity, trapezium ridge, TCLI: Proximal 1st phalanx, lateral baseN: MedianF: ABduction of CMC & MCP of thumb
95
Name the OINA of Flexor Pollicis Brevis
O:- Superficial Head: trapezium- Deep Head: trapezoid, capitate and palmar ligaments of distal carpal bonesI: Base of 1st proximal phalanx on radial side & extensor expansionN:Superficial: medianDeep: ulnarF: CMC & MCP thumb flexion
96
What is the innervation of flexor pollicis brevis?
Superficial head: median nerveDeep head: ulnar nerve
97
What is the OINA of opponens pollicis?
O: Trapezium & TCLI: 1st MC shaft, radial sideN: medianA: Opposition
98
Name the OINA for adductor pollicis
O:Oblique head: capitate, base of 2/3 MCTransverse head: proximal 2/3 of palmar surface of 3rd MCI: base of 1st proximal phalanx, ulnar sideN: ulnar nerveA: adduction of 1st CMC
99
Name the OINA for abductor digiti minimi:
O: pisiformI: base of 5th proximal phalanx, ulnar sideN: ulnarA: Abduction of 5th MCP/digit
100
Describe the OINA for flexor digiti minimi
O: hamate, TCLI: Proximal 5th phalanx, ulnar sideN: ulnarA: flexion of 5th digit/MCP
101
Name the OINA for opponens digiti minimi
O: hook of hamate, TCLI: 5th MC - entire ulnar borderN: ulnarA: 5th MCP flexion and rotation of entire 5th digit
102
What is a test you can do for ?Boutonniere's Deformity how do you do it?
Elson's Test:Tests for central slip ruptureFlex PIP to 90 deg over a table edgeget them to actively extend PIPJif they can, then central slip is intactif they cannot, then central slip is disrupted - lateral bands sublux volar to axis of PIPJ and pull on extensor tendon will cause flexion instead
103
Name the OINA of the lumbricals
O: Tendons of FDPI: extensor expansion on dorsal aspect of each digitit's radial sideN:1,2: median3,4: ulnarA:MCP flexion 2-5th digitsDIP & PIP extension of 2-5th digits
104
How do the lumbricals exert their function?
They relax it's own antagonist (FDP) when they are contractingIt originates from the FDP muscel tendonWhen it is relaxed, and the FDP contracts, the IP joint flexesWhen the lumbricals contract, it extends the IP joint by relaxation of the FDP tendon distal to the lumbrical origin and by proximal pull on the lateral band and dorsal aponeurosis
105
Descirbe the pathoanatomy of a swan neck deformity
Lesion: Hyperextension of PIP + flexion of DIPPrimary lesion: Lax volar plate caused by:- Trauma- Generalized Laxity- RASecondary lesion: Imbalance of forces on PIP joint (PIP extension > PIP flexion). Causes:- Mallet finger: leads to transfer of DIP extension force into PIP extension forces- FDS rupture: eads to unopposed PIP extension combined with loss of integrity of the volar plate- Intrinsic contracture- MCPJ volar subluxation: in RA
106
What is the intrinsic plus position?What is the principle behind this position?
Safe position for immobilization of the handWrist in 30deg extensionMCP 70deg flexionIP neuralPrincip;s"Wrist in extension: optimal position for grip strengthMCP flexion: MCP collateral ligament at their longest in 90 deg flexion, but this is painful so only do 70 degPIP collateral ligaments: at same length throughout ROM but flexors arestronger than extensors and gaining PIP flexion is easier than gaining back extension
107
What are the junctura tendinae?
Intertendinous connectionsTransverse connections between EDC tendonsEIP & EDM not typically involved, therefore allowing for independent extension of D2 and D5Passive stabilization of extensor tendon over MC head in full flexion (fist)
108
What allows for independent motion of the index and small fingers (most of the time)?
Generally, no junctura tendinae between EIP and EDM so they get independent motion
109
What are the components of the extensor hood?
Combination of:EDC tendons --> central slipDI and PI tendons & Lumbricals --> lateral bandsOblique retinacular ligamentsSagittal bandsTriangular ligament
110
Describe the pathoanatomy of a Boutonniere Deformity:
Force causing hyperflexion at PIP jointCentral slip rupture --> more force going through terminal slip --> hyperextenio of DIP, Volar subluxation of alteral bands --> PIP hyperflexionTriangular ligament rupture --> subluxation of lateral bands --> hyperflexion of PIP --> increased extension force through DIP
111
What is Camper's Chiasm?
Where FDP passes through the 2 slips of FDS located at the PIP joint
112
Describe the blood supply to the flexor tendons
From Diffusion and Vascular supply from vincular system- Each tendon has a short and long vinculum
113
What is the blood supply to the Lunate?
Dorsal plexus: from radial and anterior interosseous arteriesVolar plexus: from radial, ulnar, anterior interossoues, recurrent branches of deep palmar arch3 different vascular patterns within lunate (see picture attached)"I" has greatest risk of AVN
114
Name the course of the radial artery
Arises from the bifurcation of the brachial artery in the cubital fossaRuns distally on anterior forearm winding laterally around the wrist radial to FCRPasses through the anatomical snuff boxThen between the heads of the first dorsal interosseous muscleIt passes anteriorly between the heads of the adductor pollicis & winds around 1st MC between heads of oblique and transverse opponens pollicisGives off major contributions fo deep palmar arch, which joins with deep branch of ulnar artery
115
Name the course of the ulnar artery
From brachial arteryArises just distal to cubital fossa (5-9cm)Deep proximally: covered by the PT, FCR, FDS; It lies on Brachialis FDPThe median nerve is in relation with the medial side of the artery for about 2.5 cm. and then crosses the vessel, being separated from it by the ulnar head of the Pronator teres.Distally in forearm, it sits on FDP being covered by the integument and the superficial and deep fasciæ, and sits between the FCU & FDSRuns with 2 venæ comitantesCovered in middle 1/3 by FCUUlnar nerve is ulnar in distal 2/3Palmar cutaneous branch of the nerve descends on the lower part of the vessel to the palm of the hand.Major contributions to superficial palmar arch
116
Course of the Anterior interossoues artery
Comes down the forearm on palmar surface of the IoMAccompanied by palmar interosseous branch of the median nerve & overlapped by FDP & FPL giving off muscular branches and nutrient vessels to radius/ulnaAt the upper border of the pronator quadratus, it pierces the IoM, winding to dorsal forearm to anastomosewith the dorsal interosseous artery.It then descends with the terminal part of the dorsal interosseous nerve to the dorsal wrist to join dorsal carpal network.Before it pierces the interosseous membrane the anterior interosseous sends a branch downward behind the pronator quadratus muscle to join the palmar carpal network.
117
Digital nerve: volar or dorsal in the finger?
Nerve becomes the most volar structure in the fingerIt gives off dorsal branches to innervate dorsal skin starting at ~mid P2
118
Name the anatomic variants of the Million Dollar Nerve
Recurrent Motor branch of the Median NerveVariants:Extraligamentous: most commonSubligamentous: nextTransligamentous: Rarest
119
Describe the course of the palmar cutaneous branch of the median nerve. What common surgery to you have to watch out for it
Arises from radial border of median nerve approximately 5 to 6 cm proximal to distal transverse flexion crease of the wrist; - it runs along the median nerve for 2 to 3 cm, and then runs along the ulnar border of the flexor carpi radialis tendon; - in some cases it may run along the ulnar side of the palmaris longus tendon; - when the tendon enters the flexor retinaculum comparment, the nerve passes between the two layers of the forearm fascia into the root of the palmar aponeurosis; - after 5-10 mm, the nerve divides into three terminal branches which cross the midpalmar aponeurosis to supply deep layers of dermis Watch out for it during Carpal Tunnel Approach and with any incision ulnar to FCR
120
Where can you find the dorsal cutaneous branch of the ulnar nerve?
emerges from under FCU and becomes subcutaneous 5cm proximal to pisiform 0.2-2cm proximal to the ulnar styloid at the subcutaneous border of the ulna
121
What is the terminal branch of the ulnar nerve and what does it supply?
Deep branch of ulnar nerveSupplies 1st dorsal interossei last
122
describe path of superficial radial nerve at the level of the wrist/hand:emerges where?branches where?
emerges from under BR, 7-9cm proximal to radial styloid tip on dorsoradial aspect of wristbranches out 5cm proximal to radial styloid tip into terminal branches
123
dorsal extrinsic wrist ligaments: what and where?
dorsal intercarpal ligament: between scaphoid and triquetrumdorsal radiocarpal ligament: between radius (ulnar side) and triquetrum
124
lunotiquetral ligament: what part is strongest?
volar
125
Name the compartments of the hand (not wrist)
there are 10Thenar compartmentAdductor pollicisHypothenar compartment - may have subcompartments4x dorsal interossei compartments3x palmar interossei compartments
126
Describe the motion of the proximal carpal row with ulnar and radial deviation of the wrist
Radial deviation: Proximal row flexes (think scaphoid)Ulnar deviation: proximal row extends
127
What structure is at risk during trigger thumb release?
Radial digital nerve because of it's oblique orientation overlying the A1 pulley
128
What is the last muscle to be reinnervated after PIN injury? Bonus marks for full order of reinnervation.
Last to reinnervate: EIPOrder of reinnervation: Goes proximal to distal:ECU, EDC, EDM, APL, EPL, EPB, EIP
129
The ulnar nerve is (radial/ulnar) and (volar/dorsal) to the artery at the level of the wrist
Ulnar nerve is ulnar and dorsal to the artery at the level of the wrist
130
What amount of wrist flexion and extension occur through the midcarpal joint?
70 degrees
131
What is the main function of the midcarpal joint?
radial and ulnar deviation
132
What is a Martin-Gruber Anastomosis?
median to ulnar n anastomosis in the forearm, somtimes AIN to ulnar. i.e. median/AIN supplies muscles normally supplied by ulnar n, so with ulnar palsy can still have intrinsic hand function
133
order of carpal bone ossification?
capitate, hamate, triquetrum, lunate, scaphoid, trapezium, trapezoid, pisiform i.e. starting with capitate, go clockwise on right wrist dorsum, with pisiform at end
