Bab 6 Hand

Topographic Anatomy

Osteology

Radiology

Trauma

Tendons

Joints

Other Structures

Minor Procedures

History

Physical Exam

Origins and lnsertions

Muscles

Nerves

Arteries

Disorders

Pediatric Disorders

Surgical Approaches

Hand . TOPOGRAPHIC ANATOMY

Common namesof digits

Anterior view

ThumblndexMiddleRingLittle

Flexor carpiradi al is

Thenar eminence

Radial longitudinalPalmaris longustendon

Flexor digitorumsuperficialis tendons

lexor carpi ulnaris tendon

em tnence

palmar crease

imal digital crease

digital creasemetacarpophalangealjoint

Distal digital crease

Extensor pollicis Anatomicsnuff boxlongus tendon

Site of thumb

ioint

metacarpophalangealjoinl

Extensortendon

interphalangeal (PlP) joinl

te of distalinterphalangeal (DlP) joint

€(4"d-

Posterior view

Extensor digitorum tendons

of proximal

Palmaris longus tendon Not present in all people. Can be used for tendon grafts,

Anatomic snuffbox Site of scaphoid. Tenderness can indicate a scaphoid fracture.

Thumb carpometacarpal joint Common site 0f arthritis and source 0f radial hand pain.

Thenar eminence Atrophy can indicate median nerve compression (e.9., carpal tunnel syndrome).

Hypothenar eminence Atrophy can indicate ulnar nerve compression (e.9., ulnar or cubital tunnel syndrome)

Proximal palmar crease Approximate location of the superficial palmar arch of the palm.

Distal palmar crease Site of metacarpophalangeal joints on volar side of hand.

I84 NETTER'S CONCISE ORTHOPAEDIC ANATOMY

fscaphoidCarpal / andbones*/ Tubercle

,/ Trapeziu6

-/ rubercle/( Iraoezoicl/,

nquetrum.Pisiform

-Capitate

-Hamate ar\Hook\8"r" I\Shafrs !,,Head )

Zt:fsj

fuit::;)fTjr- base

Kil{i

OSTEOTOGY o Hond

Right hand:anterior (palmar) view

Sesamoid[6ns5-

Right hand:posterior (dorsal) view

NETTER'S CONCISE ORTHOPAEDIC ANATOMY I85

X-ray, hand

Hond . RADroLocY

D istalIN

joint (DlP)

Proximalinterphalangealjoint (PlP)

Metacarpo-phalangealjoint

Distalphalanx(P3)

Iuft

phalanx Index

lP2)

phalanx(P1)

Disral

Thumbinterphalangealjoint (lP)

D ista I

phalanx(P3)

Middlephalanx\P2)

Proximalphalanx(Pl )

Lateral x-ray, finger

X-ray, hand X-ray, finger

T86 NETTER,S CONCISE ORTHOPAEDIC ANATOMY

TRAUMA o Hond

Metacarpal Fractures

Transverse fractures of metacarpal shaft usuallyangulated dorsally by pull of interosseous muscles

Oblique fractures tend to shorten androtate metacarpal, particularly in index

ln fractures of metacarpal neck, volar cortex often and little fingers because metacarpalscomminuted, resulting in marked instability after of middle and ring fingers are stabilizedreduction, which often necessitates pinning by deep transverse metacarpal ligaments

Fracture of Base of Metacarpals of Thumb

I st metacarpal

Bone

Trapezium

Abductor pollicislongus tendon

4fNType I (Bennett fracture). lntraarticular fracturewith proximal and radial dislocation of l st meta-carpal. Triangular bone fragment sheared off

Fracture of Proximal Phalanx

Type ll (Rolando fracture).lntraarticular fracture withY-shaped configuration

ffiffiReduction of fractures of phalanges or metacarpals requires correct rotational as well as longitudinalaliSnment. ln normal hand, tips of flexed fingers point toward tuberosity of scaphoid, as in hand at left.

. Common in adults, usually a fall

or punching mechanjsm. 5th MC most common (boxer fx). Thumb MC base fractures: dis-

placed, intraarticular fracturesproblematic

" Bennett's fx: APL deforms fx. Rolando's fx: can lead to DJD

. 4th & sth l\40s can toleratesome angulation, 2nd & 3rdcannot

Hx: Trauma, pain, swell-ing,+/- deformity

PE: Swelling, tenderness,

Check for rotational de-formity, Check neurovas-cular integrity.

XR: Hand. Evaluate for an-gulation & shonening

CT: Useful to evaluate lornonunion of fracture

By location:. Head. Neck (most common). Shaft (transverse, spiral). Base

" Thumb MCo Bennett: volar lip fx

" Rolando: commi-nuted

. Small finger lVlC:

"Baby Bennett"

. Nondisplaced: cast

. Displaced: reduce

" Stable: cast. Unstable: CR-PCP

VS, ORIF

" Shortened:0RlF. lntraarticular

" Head:oRlF. Thumb base:

. Bennett:

CR-PCPo Rolando: oRlF

NFITER,S CONCISE ORTHOPAEDIC ANATOMY T87

Hond . aAUMA

iij.i

i1

'1+.

iii'

T

a

t1i

::''li'rtiit

rffim:J affi,q*# r

lntraarticular condyle fractures.

Fractures of distal phalanx

@%eTypes of fractures.A. LongitudinalB. Nondisplaced transverseC. Angulated transverseD. Comminuted

Phalangeal Fractures

lntraarticular phalangeal baseftacture. lntraarticular fracturesof phalanx that are non-displaced and stable maybe treated with buddytaping, careful observation,and early active exercise.

4{ffi4't'/

Extraarticular oblique shaft(diaphysis) fracture.

Extension block splint useful for fracture dislocation of proximal

. Common injury

. l\ilechanism: jamming, crush,

or tlvisting. Distal phalanx most common. Stitfness is common prob-

lem; early motion and occu-pational therapy needed forbest results

. lntraarticular fractures canlead to early osteoarthritis

. Nail bed injury common W/

tuft (distal phalanx) tx

Hx: Trauma, pain,

swelling, +/- deformityPE: Swelling, tenderness,

Check for rotational de-

formity. Check neurovas-

cular integrity.

XR: Hand. Evaluate forangulation & shoftening

CT: Useful to evaluate fornonunion of fracture

Description:. lntra- vs extraartrcular. Displaced/

nondisplaced. Transverse, spiral,

oblique

Location:. Condyle. Neck. ShafYdiaphysis. Base. Tuft

. Extraarticular:

" Stable: buddy tape/splint

" Unstable: CR-PCP vs

ORIF. lntraarticular: oRlF. l\4iddle phalanx volar

base fx:. Stable: extension block

splint

" tinstable: 0RlF. Tuft fx: inigate wound,

repair nail bed asneeded, splint fxldiqit

r88 NF|TER'S CONCISE ORTHOPAEDIC ANATOMY

Gamekeeper's thumb

A. Tendon torn fromits insertion. B. Bonefragment avulsed withtendon. ln A and B

there is a 40"- 45'flexion deformityand loss of activeextension

Ruptured ulnarcollateral ligamentof metacarpopha-langeal joint ofthumb

Flexor digitorum profundus tendon may be torn directly fromdistal phalanx or may avulse small or large bone fragment.

TRAUMA O Hond

Mallet finger

Splinted Mallet Finger

Adductor pollicis m.andaponeurosis (cut)

4w

. Rupture of extensor tendon

from distal phalanx. Soft tissue or bony form. l\,4ech: jamming finger

Hx: "Jammed" finger;pain, DIPJ deformity

PE: Extensor lag at DIPJ;

inability to actively ex-tend DIPJ

XR: Hand series. Look forbony avulsion (EDC) tx

from dorsal base of P3

in bony form of injury

i, DIPJ extension splint,

6wk for most injuries

2, Bony mallet with DIPJ

subluxation: considerPCP vs OR|F

. FDP tendon rupture from P3

. l\4ech: forced extension

against a flexed finger. Tendon retracts variably

Hx: Forced DIPJ exten-sion, injury; pain

PE: lnability to flex DIPJ

(-profundus test)

XR: Hand series. Look foravulsion fracture from

volar base of P3. lVay

be retracted to finger/palm.

Leddy classif ication: Type:. 1: to palm. Early repair. 2: to PIPJ. Repair <6wk. 3: bony to 44: 0RlF

;aiii:itrilli,ii:,i:i,l. Thumb IMCP joint proper ul

nar collateral ligament injury. l\4ech: forced radial deviation. 0ften a ski pole injury

Hx: Pain, decreased grip

PE: Pain & laxity ofIMCPJ at 30' of flexion,+/- palpable mass

$tenor lesion)

XR: Hand; r/o avulslon tx

Stress Fluoro: Can com-pare side to side asym,

MR: lf diagnosis is un-clear

. Incomplete tear (sprain)

or no Stenor lesion:

splint 4-6wk. Complete tear or Stenor

lesion: primary repair

NETTER,S CONCISE ORTHOPAEDIC ANATOMY I89

Hond . TENDoNS

I DIP

ll Middleilt PtP

Flexor zones of hand lV Proximal phalanx

Vlll Distal forearm

Extensor zones of hand

I-l lP joint

T-ll Proximal phalanx

I-lll MP joinl

-lV Metacarpal

T-V CMC joint radial styloid

JclrNA"cRA\-"ao

VI

Vll Dorsal retinaculum

Distal to FDS

insertionSingle tendon (FDP) injury. Primary repair. DIPJ contracture results if tendon short-

ened >1cm. Quadriga effect can also result

il Finger flexor

retinaculum

"No man's land," Both tendons(FDs, FDP) require early repair (within 7 days) and mo-bilization. Lacerations may be at different locaiions on each tendon and away fromskin laceration. Preserve A2 & A4 pulleys during repair

ilt Palm Primary repair. Arterial arch & median nerve injuries common.

IV Carpal tunnel Must release & repair the transverse carpal ligament during tendon repair

Wrist & forearm Primary repair (+ any neurovascular injury), Results are usually favorable.

Thumb I Distal to FPL

insertion

Primary tendon repair. Rerupture rate is high.

Thumb ll Thumb flexor

retinaculumPrimary tendon repair. Preserve either A.1 or oblique pulley

Thumb lll Thenar eminence Do not operate in this zone. Recurrent motor branch is at risk of injury,

DIP joint "Mallet finger." Splint rn extension for 6 wk continuously.

il Middle phalanx Complete lacerations: primary repair and exiension splint.

ilt PIP joint Central slip injury. Splint in extension for 6 wk. lf triangular ligament is also disrupted,lateral bands migrate volarly, resulting in "boutonniere finger"

ru Proximal phalanx Primary repair of tendon (and lateral bands if needed), then extension splint

MCP joint often from "fight bite." Repair tendon and sagittal bands as needed

VI l\4etacarpal Primary repair and early mobilization/dynamic splinting.

vil Wrisl Retinaculum likely injured. Primary tendon repair, early mobilization.

vil Distal forearm At musculotendinous jxn. Primary repair of tendinous tissue & immobilize

IX Proximal forearm 0ften muscle injury Neurovascular injury high. Repair muscle & immobilize,

T90 NETTER,S CONCISE ORTHOPAEDIC ANATOMY

Tendons of flexor digitorumsuperficial is

and profundusmuscles

(Synovial) tendinous

Common palmar digital

Proper palmar digital arteries and nerves

Annular and cruciform parts of fibrousover (synovial) flexor tendon sheaths

plates (palmar ligaments)

Superficial palmarbranch of radialartery and recurrentbranch of mediannerve to thenarmuscles

UInar arteryand nerve

Common palmardigital branchesof median nerve (cut)

muscles

sheath (u lnarbursa)

th finger(synovial)tendinous sheath

profundus tendon

l{ffii.l'/C//dda,A

NETTER'S CONCISE ORTHOPAEDIC ANATOMY I9I

Hond . lotNTs

Posterior (dorsal) view

Dorsal carpometacarpal I

Dorsal metacarpal I

Capitate

Trapezium

Capsule of 1 st carpo-metacarpal joint

Trapezoid

t{ffi4{/

r92 NETTER'S CONCISF ORTHOPAEDIC ANATOMY

Anterior (palmar) view

Trapezium

lotNnt o Hond

Pisiform

Hook of hamate

Palmar carpomelacarpal ligaments

Palmar metacarpal ligaments

transversemetacarpal ligaments

plates(palmar lig,aments)

';

lexor digitorum profundus tendons

Joint.uptul"\.

Collateral liSaments

Flexor digitorum /superf icial is tendons (cuf)

4{tr

Itllffitfs I

rlclilEtl trnHffiilS ..,.,.::

. Diarthrodial joint. Motion: primarV = flexion & extension; qecondary = r0tation, adduction, abduction

Capsule Surrounds joint Secondary stabilizer dorsally Taut in {lexion

Center ol metacarpal head topalmar Proximal Phalanx

Primary stabilizer. Taut in flexlon, test in 30' flexion

Ulnar Collateral injured in "gamekeeper's/skier s" thumb

Accessory collateral Palmar to proper collateral lig. Taut in extension Test integrity in extension'

Primary stabilizer in extension Laxity in extension indi-

catesiniury t0 volar plate (+/- accessory collateral lig )Volar (palmar) plate Palmar metacarpal head to pal-

mar proximal phalanx base

. Diarthrodialjoint. Molion: primary = flexion & extenliol

. Asymmetry of metaearpafhead & collateral ligamenlori

0-90"); secondary : radial & ulnar deviation

rssult in 'tam effect" (tight in flexion, lcj:ose in extension)

Capsule Sunounds joinl Secondary stabilizer; synovial reflections volar & dorsal

Proper collateral Dorsal MC head to palmar P1 Primary stabilizer; tight in flexion, loose in extenslon

Accessory collateral palmar MC head to volar plate Palmar to proper collaterals; stabilizes the volar plate

volar (palmar) plate Palmar MC head to palmar P1 Limits extension; volar suppon

base

Between adlacent metacarpal

bases and MCPJ volar Plates

lnterconnects the volar plates, MCPJs, and metacarpals.

Can prevent shortening oJ isolated metacarpal fracturesDeep transverse(inte0metacarPal


Hond . lotNTs

Flexor digitorumprofundus (FDP)

tendon

Volar plate of PIPJ

Flexor digitorumsuperficialis (FDS)

tendon

Proximalphalanr (P1 )

Extensor tendon

Cleland's lig..

Lateral digital sheet

Neurovascular bundleDigital a.

Digital n.

Crayson's

Accessorycol Iateral

Proper collateral Iigamenl

Palmarsurface Proximal

,Dista I

/lnterpha langea I

- / rotet loint

F<,;:: Distal

Note: Ligaments of "'b * :i

metar arpophalargeal . 'r. " t'

and interphalangeil ' ' li€ *-

joints are similar -# " '

ln flexion: medial view

Phalangesln extension:medial view Volar (palmar Iigament)

Accessory collateral

Metacarpophalangeal (MP) joint

31i,,,u".n \

J L,ffi^.1'/JOHtrA.CRAt.-ao

Proximal interphalangeal

ioint

{'=* r'i4f* .***+*'tiEf'vot^,

ptut",

PBOXIMAT INT.FRPHATAI\IGEITL

Capsule Sunounds joint Weak stabilizer esp. dorsally (central slip adds most suoport)

Proper collateral Center of Pl head to volar P2 Primary stabilizer to deviation, Constant tension through ROM

Accessory collateral Volar proximal phalanx head

to volar plate (not bone)

Origin volar to axis of rotalion: tight in ext., loose in flexionThis can result in a contracture (do not immobilize in flexion)

Volar (palmar)

plateVolar middle phalanx to volar

proximal phalanx (via check-rein ligaments)

Primary restraint t0 hyperextension. Firm distal attachment,looser proximal attachment (more prone to injury).

Checkrein ligaments Often contract after iniury: contracture

OTHER IT{IERPHALAJ{GEAL

Capsule Surrounds joints Weak stabilizer

Proper collateral B/w adjacent phalanges Similar io PIPJ, constant tension, no "cam effect"

Accessory collateral Volar to collateral ligaments Similar to PIPJ, less prone to contracture than PIPJ

Volar (palmar) Volarly b/w phalanges Primary restraint t0 hyperextension; can be injuredplate

OTHER STRUCTURES

Grayson's ligament From flexor sheath to skin; volar

to neurovascular bundle

Stabilizes skin & neurovascular bundlelnvolved in Dupuytren's disease/nodules

Cleland's ligament From periosteum to skin Stabilizes skin during flexion/extension; dorsal to NV bundle

I94 NEITER,S CONCISE ORTHOPAEDIC ANATOMY

lnsertion of small deep slip of extensor tendonto proximal phalanx and joint capsule

Extensor expansion (hood)

Sagittal band

Attachment of interosseous m.to base of proximal phalanxand joint capsule

, :! :::|N

,gi#

Collateral lig.

Lumbrical m

Note: Black arrows indicatepull of long extensor tendon;red arrows indicate pullof interosseous andlumbrical muscles; dotsindicate axis ofrotation of joints.

IOINTS r Hond;

lnterosseous mmVolar plate(palmar ligament)

Flexor digitorumtendon (cut,

Conjoined lateral

Finger in flexion:lateral view

Terminal extensortendon insertion

lateral ligs

Flexor digitorumprofundus tendon (cut)

plate(palmar ligament)

6ry&4

lnsertion of;;;;;#;il; /+Central band rlrp/ " I

Metacaruophalangeal Joinl

Flexion lnterosseous muscles lnsert on proximal phalanx and lateral band (volar torotation axis)

Lumbricals lnserts on radial lateral band (volar to axis 0f rotationof t\itcPJ)

Sagittal bands insert on volar plate, creating a "lasso" aroundproximal phalanx base and extend joint through the lasso.

EDC has minimal attachment to Pl (which does not extendthe joint) but extends joints via the sagittal bands,

Proximal lntenhalangeal Joint

Flexion Flexor digitorum superficialis Primary PIPJ flexor via insertion on middle phalanx volar(FDS) base

Flexor digitorum profundus Secondary PIPJ flexor(FDP)

EDC via the central slip (band)

Lumbricals via lateral bandsCentral slip of EDC inserts on dorsal P2 base to extend PIPJ

Has attachment to radial lateral band (dorsal to rotation axis)

Distal Interphalangeal Joint

Flexor digitorum profundus

(FDP)

Tendon attaches at P3 volar base, pulls through tendonsheath

EDC via terminal extensortendon

0blique retinacular ligament(0RL)

Lateral bands converge at terminal insertion on dorsalP3 base

Links PIPJ & DIPJ extension; extends DIPJ as PIPJ is

extended

NETTER'S CONCISE ORTHOPAEDIC ANATOMY I95

Hond . orHER srRucruREs

lnsertion of central slip of extensortendon to base of middle phalanx

Triangular (aponeurosis)Iigament

Posterior(dorsal)view

Conjoined

Lateralbands

Extensorexpansion

Sagittalbands

lateral bands

Lateral slips o{long extensor

extensor tendon

lnterosseous muscles

Metacarpal bone

of interosseoustendon passes to baseof proximal phalanrand joint capsule

x$%o**tendon slip to

tendon to lateral bands lateral band muscle

Central Oblique Extensor expansion (hood)

Lateral Sagiftal bands Long extensor tendonlnsertion of extenso, tundon-

Iut"tul b"nd'

to base of middle phalanx rp

lnsertion of terminal extensortendon to base of distal phalanx

Finger inextension:lateral view

;*:;r;;-- \Lumbrical muscle

Flexor digitorum profundus tendon

Flexor digitorum superf icialis tendon

bone

muscles

. Dorsal ExtensorAponeurosis (also called dorsal expansion, dorsal hood, extensor hood)

lnserts on volar plate (Pl); extensor tendon(EDC) glides under it

Extends MCPJ via "lasso" around Pl base;

radial sagittal bands are weaker, may rupture

" Oblique fibers Covers |\4CPJ and base of proximal phalanx Holds EDC centered over MCPJ

Volar to MCPJ axis: flexes MCPJ

Dorsal to PIPJ axis: extends PIPJ

Lateral hood libers join tendinous portion ofinterossei/lumbricals to form lateral bands

' Extrinsic ExtensorTendon (EDC) glides underthe dorsal hood (to extend MCP) before trifurcating at prox. phalanx

. Lateral slip EDC trifurcates over Pl giving two lateral slips These slips conjoin with lateral bands

' Central slip Central slip oJ trifurcation; inserts base of P2 Extends PIPJ; torn in boutonniere injury

. Terminal extensor Confluence o1 two conjoined lateral bands on Extends DIPJ via insertion on dorsal base oltendon dorsal base of distal phalanx (P3) P3; avulsed in mallet finger injury

Confluence o{ EDC lateral slips and lateralbands from extensor aponeurosis

Both join distally to make terminal extensortendon

. Conjoined lateral

band

. Transverse retinacular From PIPJ volar plate and flexor sheath toligamenis both conjoined lateral bands

Prevents conjoined lateral band dorsal sub-luxation during PIPJ extension

Transverse bands over P2, connects bothconjoined lateral bands and terminal iendon

Prevents lateral band volar subluxation in

PIPJ flexion; torn in boutonniere injury

. Triangular ligament(aponeurosis)

' 0blique retinacular From volar Pl to dorsal P3/terminal tendon Extends DIPJ when PIPJ is extendedligament (ORL)

Tendinous connections between ECD ten-dons to adjacent fingers proximal to MCPJ

Prevents full extension of finger when adja-cent digit is flexed (see page 1 55)

196 NETTER'S CONCISE ORTHOPAEDIC ANATOMY

Tendinous sheathof flexor pollicislongus (radial bursa)

Common flexorsheath (ulnar bursa)

fhenar space

Midpalmarspace

Lumbrical(in fascialsheaths)

Tendinous sheath offlexor pollicis longus(radial bursa)

OTHER STRUCTURES O HONd

Commonflexor sheath(ulnar bursa)

Flexor digitorumsuperficialis tendons

flexor sheath(ulnar bursa) (opened)

Lumbrical muscles infascial sheaths

Midpalmar space(deep to flexor tendonsand lumbrical muscles)

Fibrous and synovial (tendon)sheaths of finger (openea)

Flexor digitorum superfi cialistendon (FDS)

Flexor digitorum profundustendon (FPS)

Flexor pollicis longus ten-don in tendon sheath(radial bursa)

pollicis

Flexor digitorumprofundustendons

Tendinoussheath of flexorpollicis longus(radial

Synovial tendonsheaths of fingers

Fascia of adductor pollicis

Thenarspace -..'.-(deep to flexor tendonand lst lumbrical muscle)

(Synovial) tendinoussheath of finger

Lumbrical muscles in fascialsheaths (cut and reflected)

g

]ilffiLl."

Midpalmar

Palmar

Common palmar digitalartery and nerue

Lumbrical musclein its fascial

Flexor tendons to 5thdigit in common flexorsheath (ulnar

Hypothenar musc

Dorsal interosseous

Prolundus and superficiali' ilexor tendons to 3rd digitbetrveen midpalmar and thenar spaces

space

longus tendon

pollicis muscle

Palmar interosseous fascia

Palmar interosseorrs mrrscles

Dorsal interosseous muscles

xtensor lendons

NETTER'S CONCISE ORTHOPAEDIC ANATOMY T97

Hond . OTHER STRUCTURES

Nail matrix

Sagittal section(germinal

Nail

Eponychium (cutic

LunulaNa il he.l

-(sterile matrir)

Body of nail

Distal phalanx

Epiphysis

I Nerves Arteries Septa I

membrane

Articular cartilage Extensor digitorum tendon

Middle phalanx

digitorumsuperficialis tendr

Fibrous tendonsheath finger

al (flexor tendon) sheathfinger

digitorum profundus tendon

Palmar ligament (plate)

Body of nail

Nail bed

Distal phalanx

Fibrous septa and areolartissue in anteriorclosed space (pulp)

Dorsal digital artery and nerye

palmar digital artery

Distal anterior closed space (pulp) Articular cavity

Cross sectionthrough distalphalanx

Dorsal branches of proper palmardigital arteries and nerves to dorsumof middle and terminal phalanges

Arteries and nerves

4{Y;Nutrient branch to epiphysis

Nutrient branches to metaphysii Proper palmar digital artery and nerue

T98 NFTTER,S CONCISE ORTHOPAEDIC ANATOMY

Thumb CMC lnjection Digital Block Digital block, bothsides of base offinger

Flexor Sheath lnjection

3i:l.i1li:*.*:*i:i:.Si1,*i itf.lE t.,i_1;:*i..1:::i*

1. Ask patient about allergies

2. Palpate thumb CMC joint on volar radial aspect

3. Prepare skin over CMC joint (iodine/antiseptic soap)

4. Anesthetize skin locally (quarter size spot)

5. Palpate base of thumb l\4C, pull axial distraction 0n thumb with slight flexion to open joint. Use 22 gauge or smallerneedle, and insert into joint (if available use an image intensifier to confirm needle is in joint). Aspirate t0 ensure nee-dle is not in a vessel. lnject 1 -2 ml of 1:.1 local (without epinephrine) /corticosteroid preparation into CMC joint. fhefluid should flow easily if needle is in joint)

6, Dress injection site

1. Ask patient about allergies

2. Palpate the flexor tendon at ihe distal palmar crease over metacarpal head/Al pulley.

3. Prepare skin over palm (iodine/antiseptic soap)4. lnsert 25 gauge needle into flexor tendon at the level of the distal palmar crease. Withdraw needle very slightly so

that it is just outside tendon, but inside sheath. lnject 2-3ml of local anesthetic without epinephrine. (Add corticoste-roid if injecting for trigger finger).

5. Dress injection site

1. Prepare skin over dorsal proximal finger web space (iodine/antiseptic soap)

2. lnsert 25 gauge needle between metacarpal necks (metacarpal block) or on eiiher side of proximal phalanx (digital

block) in digital web space. Aspirate to ensure that needle is not in a vessel. lnject l -2ml of local anesthetic (without

epinephrine) on both sides of the bones. Consider injecting local anesthetic dorsally over the bone as well,3, Care should be taken not to inject too much fluid into the closed space of the proximal digit.4, Dress injection site


Hond . HtsroRY

Fractures and dislocations of thumb

tnjury to proximal phalanx ormetacarpophalangeal joint of thumbcaused by fall with outstretchedhand on ski pole

Fight bite

Penetration ofmetacarpophalangealjoint by tooth in fist fight

Boxer fracture

Fractures of metacarpalneck commonly resultfrom end-on blow of fist.Often called street-fighteror boxer fractures

Mallet finger

Usually caused by direct blow on extended distalphalanx, as in baseball, volleyball

n

ft{r

1. Hand dominance Right or Ieft Dominant hand injured more often

2. Age Young Trauma, infectionMiddleage-elderly Arthritis,nerveentrapments

3. Pain

a. onset

b. Location

Trauma, infection

ArthritisArthritis (0A) especially in womenArthritis (osteoarthritis, rheumatoid)Purulent tenosynovitis (+ Kanavel signs)

Acute

Chronic

CMC (thumb)

Joints (MCPS, lPs)

Volar (fingers)

4. Stiffness ln AM, "catching" Rheumatoid arthritisCatching/clicking Trigger finger

After trauma

No traumalnfection (e.9., purulent tenosynovitis, felon, paronychia)

Trigger finger, arthritides, gout, tendinitis

Ganglion, Dupuytren's contracture, giani cell tumor

Fall, sports injury

0pen woundFracture, dislocation, tendon avulsion, ligament injurylnfection

8. Activity Sports, mechanical Trauma (e.9., fracture, dislocation, tendon or ligament injury)

9. Neurologic symptoms Pain, numbness, tingling

Weakness

Nerve entrapment (e.9., carpal tunnel), thoracic ouflelsyndrome, radiculopathy (cervical)

Nerve entrapment (usually in wrist or more proximal)

10' Historyof arthritides Multiple jointsinvolved Rheumatoidarthritis,Reitefssyndrome,etc.

2OO NETTER,S CONCTSE ORTHOPAEDIC ANATOMY

Rheumatoid arthritisBoutonniere deformity of indexfinger with swan-neck deformityof other fingers

PHYSICAL EXAM . Hond

OsteoarthritisHeberden's nodes seen in index and middle fingerdistal interphalangeal joints. Bouchards nodes seenin proximal interphlangeal joints of the ring andsmallfinger

Rotation displacement of ringfinger. All fingers should pointtoward scaphoid when clenched

Median nerve compressionAtrophy of thenar musclesdue to compression of mediannerve

Gross deformity Ulnar drift/swan neck, boutonniere Rheumatoid arthritis

Rotational or angular deformity Fraciure

Finger position Flexion Dupuytren's contracture, purulent tenosynovitis

Rotation of digit Fracture (acute), fracture malunion

Skin, hair, nail changes Cool, hairless, spoon, etc Neurovascular disorders: Raynaud's, diabetes,nerve rnlury

0steoarthritis: Heberden's nodes (at DlPs: #1),

Bouchard's nodes (at PlPs)

Rheumatoid arthritis

Purulent tenosynovitis

DIPS

PlPs

MCPs

Fusiform shape finger

Thenar eminence

Hypothenar eminence/intrinsics

Median nerve injury, CTS, CB/|1 pathology

Ulnar nerve injury (e.9., cubital tunnel syndrome)

NETTER'S CONCISE ORIHOPAEDIC ANATOMY 2OI

Hond . PHYSIcAL ExAM

of the fingers

Flexion contracture of 4th and 5th fingers (most common).Dimpling and puckering of skin. Palpable fascial nodulesnear flexion crease of palm at base of involved fingerswith cordlike formations extending to proximal palm

Patient unable to extend affected finger. lt can beextended passively, and extension occurs with distinctand painful snapping action. Circle indicates point oftenderness where nodular enlargement of tendons andsheath is usually palpable

Purulent tenosynovitis.Four cardinal signs of Kanavel

4. Tenderness along tendon sheath

Stenosing tenosynovitis(trigger finger)

lnfections

ffiffigffiw@ilwffitWParonychia 4 ff87

4 t'/Felon

Warm, red

Cool, dryInfection

Neurovascular compromise

Metacarpals Each along its length Tenderness may indlcate fracture

Phalanges and finger joints Each separately Tenderness: f racture, arthritisSwelling: arthritis

Thenar eminenceHypothenar eminencePalm (palmar fascia)

Flexor tendons: along volar fingerAII aspects of finger tip

Wasting indicates medjan nerve injuryWasting indicates ulnar nerve injuryNodules: Dupuy,tren s contracturei snapping41 pulley with finger extension: trigger finger

Tenderness suggests purulent tenosynovitisTenderness: paronychia or felon


PHYSICAT ExAM . Hond

J6FINA.€RAK,J^6I

Normal thumb

Ulnardeviation

Normal finger flexion is

composite of flexion ofMP, PlP, and DIP jointsand allows fingertip totouch distal palmar crease

Range of thumb opposition

opposition is compositeof movemens of CMC,MP, and lP joints.Normal range is to base

NETTER'S CONCISE ORTHOPAEDIC ANATOMY 2O3

Hond . PHYSIcAL EXAM

Sensory testing

Ulnar nerve CB-T1 Radial nerve CS-CB

Sensorydistribution Sensorydistribution

Motor testing

Finger abduction.Interosseous m.Ulnar n. T1

4 f,ffi c//4,a/*4'l'/ ;onxo,cRA\-.,ro

Two-pointdiscrimination

Thumb extension.EPL. Radial nerve(PrN). C7

Finger extension.EDC. Radial nerve(PrN). C7

Anterior interosseous nerve dysfunction (paresis of flexordigitorum profundus and flexor pollicis longus muscles).

Median nerve C5-Tl

Sensory distribution


PHYstcAt EXAM . Hond

When pinching a pieceof paper between thumband index finger, thethumb lP joint will flexif the adductor pollicismuscle is weak (ulnarnerve paralysis).

Thumb instability test

x{Y\fiv,iltrJBITNA.cRA\..ao

Elson test

Normal intact central slip

Stress test for ruptur-ed ulnar collateralligament of thumb(gamekeeper thumb) Abnormal ruptured central slip

Profundus test Stabilize PIPJ in extension, flex DIPJ only lnability to flex DIP alone indicates FDP pathology

Sublimus test Extend all fingers, flex a single finger at PIPJ lnability to flex PIP of isolated finger indicates FDS

pathology

Froment's sign Hold paper with thumb and index finger, pull

paperlf thumb lP flexion is positive, suggest adductor

pollicis weakness and/or ulnar nerve palsy

CMC grind test Axial compress and rotate CMC j0int Pain indicates arthritis at CIVC joint of thumb

Finger instabil- Stabilize proximal joint, apply varus and valgus Laxity indicates collateral ligament injury

ity test stress

Thumb Stabilize MCB apply valgus stress in extension

instability test and 30'of flexion

Laxity at 30": ulnar collateral ligament injury

Laxity in extension: accessory collateral ligament

and/or volar plate injury

Bunnell-Littler Extend MCPJ, passively flex PIPJ Tight or inability t0 flex PIPJ, improved with MCPJ

test flexion indicates tight intrinsic muscles

Elson test Flex PIPJ 90'over table edge, resist P2 exten- DIPJ rigidly extending (via lateral bands) indicatession central slip injury (boutonnidre)

NEITER S CONCISE ORTHOPAEDIC ANATOMY 205

Hond . oRtctNs AND tNsERnoNs

Abductor pollicis

Abductor pollicis

Opponens pollic

Flexor carpi r

Abductorbrevis

Flexor pollbrevis

Flexor pollicislongus

Adductor

ObliqueIransverse head

Flexor digitorum superf icial is


Palmar view

lexor pollicis brevis

Flexor carpi ulnaris

digiti minimi

Flexor digiti minimi brevis

carpi ulnaris

digiti minimi

Volar interossei

Abductor digiti minimi

lexor digiti minimi brevis

Muscle attachmentslI OriginsI lnsertions

Extensor carpiradialis brevis

Extensor carpiradialis brevis

Extensor carpiulnaris

Abductor pollicislongus

1ff,ffi4,t'/

Extensor digitorumcommunis (central slip)

Extensor digitorumcommunis (terminaltendons)

Dorsal vieri,

TrapeziumAbductor pollicis brevis

Flexor pollicis brevis

0pponens pollicis

CapitateAdductor pollicis

HamateFlex. digiti minimi brevis

0pponens digiti minimiPisilormAbductor digiti minimi

Dorsal interosseous

Palmar interosseous

Adductor pollicis

Abd. pollicis longus

0pponens pollicis

0pp. digiti minimiFlexor carpi radialis

Flexor carpi ulnarisExt. carpi rad. longus

Ext. carpi rad. brevisExtensor carpi ulnaris

Proximal phalanx

Ext. pollicis brevis (thumb)

Dorsal interossei

Abductor digiti minimi

Middle phalanx

Extensor digitorum com-munis (central slip)

Distal phalanx

Ext. pollicis longus(thumb)

Extensor digitorum com-munis (terminal tendon)

Proximal phalanx

Abductor pollicis brevis (thumb)

Flexor pollicis brevis (thumb)

Adductor pollicis (thumb)

Palmar interossei

Flexor digiti minimi brevisAbductor digiii minimi

Middle phalanx

Flexor digitorum superficialisDistal phalanx

Flexor pollicis longus (thumb)


206 NEI TER S CONCISE ORTHOPAEDIC ANATOMY

Anterior (palmar) view

Radial artery and palmar carpal branc

Ra

Superfieial palmar branch o[ radial artery

MUSCTES . Hond

Pronator quadratus muscle

Ulnar nerve

Ulnar artery and palmar carpal branch

Flexor carpi ulnaris tendon

lmar carpal arterial arch

form

digiti minimi muscle lcut)Deep palmar branch of ulnar arteryand deep branch of ulnar nerve

digiti minimi brevis muscle (cut)

Opponens digiti minimi muscle

Deep palmar (arterial) arch

metacarpal arteries

palmar digital arteries

transverse metacarpal ligaments

Transverse carpal ligamenl

Branches of median nerve

(f leror retinacu lu m ) lref I ected)

Opponens pollicis muscle

to thenar muscles and to 1 st

and 2nd lumbrical muscles

Abductor pollicisbrevis muscle lcut)

Flexorbrevis muscle

Adductormuscle

1 st dorsalinterosseous muscle

Branches from deepbranch of ulnar nerveto 3rd and 4th lumbricalmuscles and to allinterosseous muscles Lumbrical riuscles trel/ected)

NETTER,S CONCISE ORTHOPAEDIC ANATOIVIY 207

Hond . MUscLEs

1 st and 2nd lumbrical(un ipennate)

Posterior(dorsal) view

Abductor digitim tnlmt

Lumbrical muscles

lnterosseous muscles

Palmar interosseousRadius muscles (unipennate)

Radial arterv Deep trdnsverse' metacarpal

Abductor pollicis ligamentsbrevis muscle

Dorsalinterosseous

3rd and 4th lumbrical muscles(bipennate)

Flexor digitorumsuperficialis tendons (cut)

extensor expansions(hoods)

-il;':l::,", c/fddal*

4{ffirT\/

Lumbricals 1 &2 FDPtendons(radial 2)

Lumbricals3&4 FDPtendons(medial 3)

l\4edian Extend PlP, flex Only muscles in bodyl\4CP to insert on their own

Ulnar Extend plp flex antagonist (FDP) Pal--i;H -' mar to deep lrans-verse lVlC ligaments.

Radial lateral

bands

Radial lateral

bands

Proximal phalanx

and extensor

expansion (lat-

eral bands)

Digit abduction DAB: Dorsal ABductMCP flexion Bipennate: each belly

has separate insertion

lnterosseous: Adjacent Fxtensor expan- Ulnar Digit adduction pAD: palmar ADductpalmar (PlO) metacarpals sion (lateral Unipennate

bands)

208 NETTER,S CONCISE ORTHOPAEDIC ANATOMY

Thenar compartment

Carpal tunnelrelease

4ftr

l)orsal inc:ision 2

Dorsal interosseouscompartments

Transversecarpal Iigament

NETTER'S CONCISE ORTHOPAEDIC ANATOMY 209

Hond . NERVES

Cutaneous innervation of the hand

Anterior (palmar) viewMedial cutaneousnerye of forearm Flexor pollicis brevis muscle

(deep head only; superficialhead and other thenar mus-

Palmar'branch

Palmar/digitalbranches

M"diun I""*" I

Adductor

4 {ffi ffJ5:4.\'/

Common palmar digital nerve

CommunicatinB branch ofmedian nerve with ulnar nerve

Proper palmar digital nerves(dorsal digital nerves arefrom dorsal branch)

I branches to dorsum ofmiddle and distal phalanges

i}ltfiiili.{llli.,,.l ii:::'-1aLi1*::,?i.r::it:1._r,.,its':!:,ii..:t1€il

:,t:::.i:::i;:iai::::;:,::'+1:::.-=!?";:i:::t!:a#

Ulnar (C[7]B-Tl): Runs in forearm under FCU,0n FDP Domal cutaneous branch divides Scm proximal to wrist. Thisnerve continues into the dorsal aspect of the ulnar digits as dorsal digital nerves. Ulnar nerve enters Guyon's canal,then divides into superficial (sensory) and deep (motor) branches. The deep branch bends around the hook of the ha-mate and runs with the deep arterial arch, The superficial branch continues into the palmar aspect of the fingers as thepalmar digital nerves.

Sensory: Dorsal ulnar handt via dorsal cutaneous branchDorsal small & ring fingers: via dorsal digital branchesUlnar proximal palm: via palmar cutaneous branchUlnar distal palm: via common palmar digital branchesPalmar small & ring fingers: via proper palmar digital branches

Motor: Superficial(sensory)branch

" Palmaris brevis-only muscle innervated by this branchDeep (motor) branch: travels with deep arterial arch. Hypothenar compartment

. Abductor digiti minimi (ADM)

. Flexor digiti minimi brevis (FDMB)

. Opponens digiti minimi (0Dl\4). Adductor compartment

" Adductor pollicis. lntrinsic muscles

" Lumbricals (ulnar two B,4l). Dorsal interossei (Dl0)

" Palmar (volar) interossei (Vl0)o Thenar compartment. Flexor pollicis brevis (FPB|--deep head only

2IO NETTER S CONCISE ORTHOPAEDIC ANATOMY

Posterior (dorsal) viewMedial cutaneous:nerve of forearm

Division between ulnar \and radial n.ru. inn"rua- |

tion on dorsum of hand is Ivariable; it often aligns withfmiddle or 3rd digit instead I

of 4th digit as shown ,,1

l- Dorsal cutaneous'lI branch and clorsal

Ulnar ] digital branches -.nerve I properpalmar/I digital branches

r Musculo-Lateral cutaneous I

. " > cutaneousnerve ot torearm I/ nerve

Posterior cutaneous Inerve of forearm I o"n,r,y Superficial branch i n".u"fu and dorsal digital I

$ branches l

Proper palmar I Mediandigital branches / nerve

NERVES T HONd

Wrist and Hand: SuperficialRadial Dissection

Lateral (radial) view

Superficial branchradial nerve

Medial branch

Lateral branch

digita I

branches ofradial nerve

n::n,

{

Abductor pollicis l:

Opponens pollic

Superficial head.of flexor pollicis \

brevis (deep

head suppliedby ulnar nerve) Ji

almarcutaneousbranch

tingbranch of mediannerve withulnar nerve

Commonpalmardigitalnerves

carpalbranchof radiala rtery

1 st and 2ndlumbricalmuscles

Dorsal branches todorsum of middleand distal phalanges

4{wProperpalmardigitalneryes

BRACIIIAL.PLEXU$

Medial and Lateral Cords

Median (C[5]B-T1)i Runs in forearm on FDP Palmar cutaneous branch branches proximal to the carpal tunnel. The

median nerve enters the carpal tunnel, The motor recurrent branch exits distal to transverse carpal ligament (ICL)

and supplies the thenar muscles. Anatomic variants include exit through (at risk in carpal tunnel release) or under the

TCL. The remainder of the nerve is sensory and supplies the palmar radial 3% digits.

Sensory: Palm of hand: via palmar cutaneous branchVolar thumb, lF, MF, radial RF: via palmar digital branchesDorsal distal thumb, lE NilF, radial RF: via proper palmar digital branch

Motor: Motor (recurrent) branch. Thenar compartment. Abductor pollicis brevis (APB)

" Opponens pollicis. Flexor pollicis brevis (FPB)-superficial head only

. lntrinsic muscles. Lumbricals (adial two [1,2])

Posterior Cord

Radial (C5-Tl): Superficial branch runs under brachioradialis to wrist, then bifurcates in medial & lateral branches thatsupply the dorsal hand & thumb web space, They continue as dorsal digital branches to the dorsal fingers.

Sensory. Dorsal radial handr via superficial branchDorsal proximal thumb, lF, MF, radial RFr via dorsal digital branches

Motor: None (in hand)

NETTER,S CONCISE ORTHOPAEDIC ANATOMY 2II

Hond . ARTERIES

Superficial palmarbranch of radial arterv

Recurrent (motor)branch of mediannerve to thenarmuscles

Adductor pollicismuscle

Proper digitalnerves andarteries tothumb

Branches of medi

UInar artery and nerve

carpal ligament(flexor retinaculum)

Deep palmar branch of ulnar arteryand deep branch of ulnar nerve

ial branch of ulnar nerve

ommon ilexor sheath(ulnar bursa)

Superficial palmar (arterial) arch

palmar digital nervesand arteries

Communicating branch ofmedian nerve with ulnar nerve

Proper palmar digital nervesand arteries

nerve to 1 st and 2ndIumbrical muscles Branches of proper palmar digital

nerves and arteries to dorsum ofmiddle and distal phalanges

4{ff lnar artery and nerve

Palmar carpal branches ofradial and ulnar arteries

'Deep palmar branch ofulnar artery and deepbranch of ulnar nerve

to

Radial artery

Superficial palmar branch of radial

Deep palmar (arterial)

Princeps pollicis

Proper digital arteries andnerves of

Distal limit of superficialpalmar arch (Kaplan's line)

Radialis indicis

Palmar metacarpalCommon palmar digital

Proper palmar digitalProper palmar digital nerves frommedian nerve

hypothenar muscles

hranchof ulnar nerve

Deep palmar branch ofulnar nerve to 3rd and4th lumbrical, all interosseous, adductor pollicis,and deep head of flexorpollicis brevis muscles

'Proper palmar digitalnerves from ulnar nerve

2T2 NETTER'S CONCISE ORTHOPAEDIC ANATOMY

Section through distal interphal-angeal joint shows irregular, hyperplastic bony nodules (Heberden'snodes) at articular margins of distalphalanx. Cartilage eroded and jointspace narrowed

Radiograph of distal interphalangeal

ioint reveals Iate-stage degenerativechanges. Cartilage destruction andmargi nal osteophytes (Heberden'snodes)

DISORDERS o Hond

Radiograph shows cartilage thinning at proximalinterphalangeal joints, erosion of carpus andwrist ioint, osteoporosis, and finger deformities

Osteoarthritis

Late-stage degenerative changes incarpometacarpal articulation of thumb

Boutonniere deformity of index finger withswan-neck deformity of other fingers

Rheumatoid arthritis

. Loss of articular cartilage

. Due to wear or posttraumatic

. DIPJ #1 (Heberden's nodes)

. PIPJ #2 (Bouchard's nodes)

Hx: Elderly or hx ol injury

Pain: worse w/activityPE: Nodule/deformity, tender-

ness, decreased R0lvl

XR: 0A findings:joint space loss,

osteophytes, scle-

rosis, subchondral

cysts

1. NSAIDS

2. Steroid injection

3. Arthrodesis/fusion

4. Afthroplasty

. Ganglion cyst from arthriticjoint (DIPJ #1)

Hx: l\4ass near a joint

PE: Mass, +/- tenderness

XR: Joint arthritis L Excision of cyst and

associated osteoph!'te

. Autoimmune disease attacks

synovium and destroys joints. MCPJ #1. Multiple deformities develop

HX: Pain and stiffness (worse

in AM)

PE: Deformities (ulnar drift,

swan neck, boutonniere)

XR: Joint destruc-

tion

LABS: RE ANA, ESR,

CBC, uric acid

1. Medical management

2, Synovectomy (1 joint)

3, Tendon transfer/repair4. Arthrodesis/arthroplasty

. FDS insertion/volar plate injury

. Traumatic or assoc. with RA

. Lateral bands subluxate dorsally, hyperextends PIPJ

Hx lnjury or RA

PE: Deformity: flexed DIPJ,

injury hyperextended PIPJ

XR: Shows bony

deformity

1. Early: splint

2. Late: surgical release

and reconstruction

3, Arthrodesis

. Central slip (EDC) and triangu-lar ligament injury

. Traumatic or assoc. with RA

. Lateral bands subluxate volarly,

hyperflexes PIPJ

Hr Traumatic injury or RA

PE: Deformity: flexed PIPJ, +Elson's test (inability to ex-

tend the flexed PIPJ)

XR: Shows bony

deformity

1. Early: splint PIPJ in

extension

2. Reconstruct lateral

bands and central slip

3. Arthrodesis/arthroplasty

NETTER,S CONCISE ORTHOPAEDIC ANATOMY 2I5

Hond . DISoRDERS

Tenosynovitis Paronychia infection

fs

tuFreAreWWEponychium elevatedfrom nail surface

Horseshoe abscess#ffiffiWW€.4WWW

4{tr

Tenosynovitis of the middle finger. Treated with zigzagvolarincision. Tendon sheath opened by reflecting cruciate pulleysFine plastic catheter inserted for irrigation. Lines of incisionindicated for tendon sheaths of other fingers (A); radial andulnar bursae (B); and Parona's subtendinous space (C)

Felon

Begins as small nodule andspreads to hand, wrist, fore-arm (even systemically).

From focus in thumb spreadsthrough radial and ulnar bursaeand tendon sheath of little finger,with rupture into Parona's sub-tendinous space

Sporotrichosis

. Tendon sheath infection

. Usu, from puncture/bite

. May spread proximally

lnto deep spaces or

Parona's space (horse-

shoe abscess)

Hx: Pain and swelling

PE: Kanaval signs (4):

1, Flexed position

2, Fusiform swelling

3. Pain w/passive extension

4. Flexor sheath tenderness

XR: Plain films. r/oforeign body, air

LABS: CBC, ESR, CRP

1. Diagnosis <24hr: lV anti-biotics, close observation(l&D if no improvement)

2, Diagnosis >24hr: trriga-lion and debridement ofsheath + lV antibiotics

. Deep infection/abscess

in pulp of finger. Staph. aureus#l

Hx: Pain & swelling

PE: Pointing abscess, edema,erythema, +/ drainage

l. lncise and drain (must re-lease septum in pulp)

2. Antibiotics (lV vs oral)

. lnfection of nail fold

. #l hand infection

. Etiology: nail biting, hangnails

Hr Pain & swellingPE: E$hema, tenderness,+/- drainage

XR: Usually not needed 1. Early: warm soaks2. l&D and oral antibiotics

3. Partial nail excision

. Infection in deep spacesor tissues (e.9., thenar,hypothenar, Parona's

[horseshoe])

Hx: Pain & swellingPE: Edema, erythema, tender-

ness, fluctuance, +/- drain-age

XR: Usually normal

MR/CT May help ifdiagnosis is unclear

1. lncise & drain, lV abx2. Wound care/dressing

changes as needed

. Fungal (Sporothrix s.)in-fection from plants/roses

. Spreads via lymphatics

Hx Rash/discoloration

PE: Early: single noduleLate: multiple nodules/rash

Potassium iodine solution

2I4 NETTERS CONCISE ORTHOPAEDIC ANATOMY

Deep space infections

DISORDERS o Hond

lnfection ofmidpalmar spacesecondary totenosynovitisof middle iinger.Focus is infectedpuncture woundat distal crease.Line of incisionindicated

Infection of thenar space fromtenosynovitis o{ index fingerdue to puncture wound.

Dupuytren'sDisease *{ffi

4.t'/

Partial excisionof palmar fasciawith care to avoidneurovascular bundles

lnflammatory thickening of fibrous sheath (pulley) offlexor tendons with fusiform nodular enlargement o{both tendons. Broken line indicates line for incisionof lateral aspect of pulley

. Usually dominant hand

. "Fight bite": fist to mouth #l

. Bacteria: Strep., Staph. a.

Human: Eikenella corr.

Animal. P a ste u re l l a m u lt.

Hx: Bite, pain & swelling

PE: Puncture wound or

laceration, edema, +/-drainage, erythema (local

or tracking proximally)

XR: Hand series: rule

out foreign body(e.9., tooth) or air

in tissues/joint[ABS: CBC, ESR, CRP

1 . Td & rabies prophylaxis

if indicated

2. l&D, wound care

3, lV antibiotics (ampicillin/

sulbactam)

lil;llWrffi Fill},'t,,'$,l'"" ""'. Tighvthickened 41 pulley en-

traps flexor tendonr Associated with DM, RA, age. Congenital form in pediatrics

Hx: 40+, pain, snapping

or locking (esp. in AM)

PE: Tender flexor sheath,

snapping with flex./ext.

XR: Usually normal

MR: Not needed, PE

is diagnostic

1. Splint, occupational rx

2. Corticosteroid injection

into tendon sheath

3. A1 pulley release

Contracture of palmar fascia

lVyof ibroblasts create thickcords of type lll collagen

Associated with northern Euro-peans (AD), DM, EtoH

Hx: Usually male, 40+,c/o hand mass

PE: Nodule in palm, +/-coniracture of MCPJ or

PIPJ

XR: Usually normal

MR: Not needed if di-

agnosis is clear. May

be useful if etiology

of mass is unclear.

1, Early (mass, no contrac-ture): reassurance

2. Late (contracture): surgi-cal excision of cords

1ii,ii:ii111i11ili,.:,!:i:i,: ,,,,,,,,,.,,,,

. Ganglion-type cyst of the

flexor tendon sheath. Most common hand mass

Hx Small volar mass

PE: Firm, "pea"-size nod-

ule, does not moveWtendon

XR: Usually normal

MR: Not needed

1 . Aspiration/puncture

2. Surgical excision ifrecurrent

lt\

NETTERS CONCISE ORTHOPAEDIC ANATOMY 2T5

; tr"d . prorRrRrc DrsoRDERs

Incision lines(prefered method)

Dorsal aspect Palmar aspect

r5t

$lt-&ti{tlIatl

I,r

*irJ

iilI

,'

i'v

!

I

:;

t;rIt:!,t

. Failure of differentiation of finger tissue

. Most common congenital hand

anomaly. Complete (to finger tip) vs incomplete. Simple (soft tissue) vs complex (bone)

Hx: Finqers are connectedPE: Fingers are connected eitherto tip or incompletely down the

fingerXR: Will determine if bones are

fused (complex)

1. Should wait approximately 1yr. tllensurgically separate fingers

2. Careful incision planning and sknqrafts improve results

. Congenital finger flexion anomaly

. Usually PIPJ of small finger

. Type 'l (infants), type 2 (adolescents)

. Etiology: abnormal lumbrical or FDS

insertion

Hx: Finger flexed. Noticed at birth

or during adolescent growth

PE: lnability to fully extend joint

XR: Shows flexion, bones tvpi-cally normal

1 . Nonoperative: stretching, splint2. Functionally debilitating contrac-

ture : surgical relemltendontransfer

. Deviation of finger in coronal plane

. Radial deviation of small finger #1

. Etio: delta-shaped middle phalanx

Hx/PE: Deviation of finger, cos-metic and functional complaints

XR: Shows delta-shaped middlephalanx

l. Mild: no freatrnent2. Functional deficit surgical

conectior/realignment osteotomy

2T6 NETTER,S CONCISE ORTHOPAEDIC ANATOMY

PEDtATRtc DtsoRDERs . Hond

Congenital constriction band syndrome

a{w

. An extra thumb or portion thereol

. Wassel classification (7 types):Type 4 is most common

. Autosomal dominant or sporadic

. Associated with some syndromes

Hx/PE: Extra thumb or portion of thumbXR: Will show bifid or extra phalanges de-

pending on which type of duplication

1. Surgical reconstruction toobtain stable thumb. Gener-ally, retain ulnar thumb/structures & reconstruct

radial side (e.9,, type 4)

. Partial or complete absence ofthumb

. Blauth classrfication: Types l- V

. Treatment based on presence ofCMC joint

. Associated with some syndromes

Hx/PE: Small to completely absent thumbXR: Range of small, shortened, or absent

bones (phalanges, metacarpal, trapezium)Evaluate for presence of the CMC joint

1. Type l: Small thumb: no

treatment2. Types ll-lllA: Reconstruction3. Types lllB-V (no CMCJ): am-

putation & pollicization

. Constrictive bands lead to digitnecrosis or diminished growth/development,

. Nonhereditary

Hx/PE: ShoMruncated fingers with bands atlevel of diminished growth

XR: Small, shortened, or absent phalanges

1. Complete amputations ifneeded

2, Release/excise bands,Z-plasty as needed for skincoverage

NETTER'S CONCISE ORTHOPAEDIC ANATOMY 2I7

Hond o SURGICAL APPRoACHES

Volar approach to finger

Midlateral approach to finger

Flexorsheath

Jointligaments

F

J&HNA,€RA\**odigitorumsuperficialis

Flexordigitorumprofundus

lexortendons

. Flexor tendons (repair/explore)

. Digital nerves

. Soft tissue releases

. lnfection drainage

. Digital artery

. Digital nerve

. Flexor tendon

. l\4ake a "zigzag" incision connectingfinger creases

. Neurovascular bundle is lateral to thetendon sheath.

. Soft tissues are thin; capsule can beincised if care is not taken.

2I8 NETTER'S CONCISE ORTHOPAEDIC ANATOMY

Bab 6 Hand

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