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 names of digits Thumb lndex

Anterior view

Middle
Ring

Little

Flexor carpi
radi al is

(4"dPalmaris longus

Thenar eminence Radial longitudinal tendon

Posterior view
Flexor digitorum superficialis tendons lexor carpi ulnaris tendon
em tnence

palmar crease imal digital crease

metacarpophalangeal

digital crease
Distal digital crease
Extensor pollicis

joint
Anatomic snuff box

longus tendon
Site of thumb

ioint
Extensor

tendon
Extensor digitorum tendons

metacarpophalangeal

joinl

of proximal interphalangeal (PlP) joinl

te of distal interphalangeal (DlP) joint

tendon Anatomic snuffbox Thumb carpometacarpal joint Thenar eminence Hypothenar eminence Proximal palmar crease Distal palmar crease
Palmaris longus

Not present in all people. Can be used for tendon grafts, Site of scaphoid. Tenderness can indicate a scaphoid fracture. Common site 0f arthritis and source 0f radial hand pain. Atrophy can indicate median nerve compression (e.9., carpal tunnel syndrome). Atrophy can indicate ulnar nerve compression (e.9., ulnar or cubital tunnel syndrome) Approximate location of the superficial palmar arch of the palm. Site of metacarpophalangeal joints on volar side of hand.

I84

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

OSTEOTOGY
fscaphoid
Carpal / bones*/
and Tubercle ,/ Trapeziu6 nquetrum .Pisiform

o Hond

/ (

rubercle/ Iraoezoicl/,
Sesamoid

-Capitate

-Hamate

\Hook

ar

\8"r"

[6ns5-

\Shafrs ! ) ,,Head

Right hand:

anterior (palmar) view

Zt:fsj
fuit::;)
fTjrbase

Kil{i

Right hand:

posterior (dorsal) view

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

I85

Hond
D IN

RADroLocY
X-ray, hand Lateral x-ray, finger
Distal phalanx
(P3)

istal

joint (DlP)
Proximal interphalangeal

Iuft phalanx Index

lP2)

joint

(PlP)

Metacarpophalangeal

joint

phalanx

(P1)
Thumb interphalangeal

Disral

joint

(lP)

X-ray, hand

X-ray, finger

D ista

phalanx
(P3)

Middle
phalanx \P2)

Proximal phalanx
(Pl
)

T86

NETTER,S CONCISE ORTHOPAEDIC ANATOMY

TRAUMA
Metacarpal Fractures

o Hond

Transverse fractures of metacarpal shaft usually angulated dorsally by pull of interosseous muscles

ln fractures of metacarpal neck, volar cortex often comminuted, resulting in marked instability after reduction, which often necessitates pinning

Oblique fractures tend to shorten and rotate metacarpal, particularly in index

and little fingers because metacarpals of middle and ring fingers are stabilized by deep transverse metacarpal ligaments

Fracture of Base of Metacarpals of Thumb

st metacarpal

Bone

Trapezium

4fN
Type ll (Rolando fracture). lntraarticular fracture with Y-shaped configuration

Abductor pollicis
longus tendon Type I (Bennett fracture). lntraarticular fracture with proximal and radial dislocation of l st metacarpal. Triangular bone fragment sheared off

Fracture of Proximal Phalanx

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

ffiffi
By location:

. . .

Common in adults, usually a fall

or punching mechanjsm 5th MC most common (boxer fx) Thumb MC base fractures: displaced, intraarticular fractures problematic Bennett's fx: APL deforms fx Rolando's fx: can lead to DJD 4th & sth l\40s can tolerate some angulation, 2nd & 3rd cannot

Hx: Trauma, pain, swelling,+/- deformity PE: Swelling, tenderness, Check for rotational deformity, Check neurovascular integrity. XR: Hand. Evaluate for angulation & shonening
CT: Useful to evaluate

. .
. .

Head

Nondisplaced: cast Displaced: reduce

Neck (most common) Shaft (transverse, spiral) Base

"

Stable: cast Unstable: CR-PCP

VS, ORIF

"

"

lor

Thumb MC o Bennett: volar lip fx " Rolando: comminuted Small finger lVlC: "Baby Bennett"

" Shortened:0RlF . lntraarticular "

nonunion of fracture

Head:oRlF
Thumb base: Bennett:

CR-PCP

o Rolando: oRlF

NFITER,S CONCISE ORTHOPAEDIC ANATOMY T87

Hond

aAUMA
Phalangeal Fractures

i
1
'1+.

::''li'rtiit

i'
T
a

i i

im
:J a ffi
lntraarticular phalangeal base ftacture. lntraarticular fractures
of phalanx that are nondisplaced and stable may be treated with buddy taping, careful observation, and early active exercise.

rff
r

t
1i

ij

i
.i

,q*#
4't'/

lntraarticular condyle fractures.

Extraarticular oblique shaft (diaphysis) fracture.

4{ffi

Fractures of distal phalanx

@%e
Types of fractures.

A.
D.

Longitudinal

B. Nondisplaced transverse C. Angulated transverse

Comminuted

Extension block splint useful for fracture dislocation of proximal

. .

. .

Common injury l\ilechanism: jamming, crush, or tlvisting Distal phalanx most common Stitfness is common problem; early motion and occupational therapy needed for best results lntraarticular fractures can lead to early osteoarthritis Nail bed injury common W/ tuft (distal phalanx) tx

Hx: Trauma, pain, swelling, +/- deformity PE: Swelling, tenderness, Check for rotational deformity. Check neurovascular integrity. XR: Hand. Evaluate for angulation & shoftening CT: Useful to evaluate for nonunion of fracture

Description: lntra- vs extraartrcular . Displaced/

.
.

"

Extraarticular: Stable: buddy tape/

splint
Unstable: CR-PCP vs
ORIF

nondisplaced Transverse, spiral, oblique

"

. .

Location: . Condyle

. .

lntraarticular: oRlF l\4iddle phalanx volar base fx: . Stable: extension block splint " tinstable: 0RlF Tuft fx: inigate wound, repair nail bed as needed, splint fxldiqit

. . . .

Neck ShafYdiaphysis Base Tuft

r88

NF|TER'S CONCISE ORTHOPAEDIC ANATOMY

TRAUMA O
Gamekeeper's thumb
A. Tendon torn from its insertion. B. Bone fragment avulsed with tendon. ln A and B there is a 40"- 45' flexion deformity and loss of active extension

Hond

Mallet finger

Adductor pollicis m.
and aponeurosis (cut)

Ruptured ulnar

collateral ligament
of metacarpophalangeal joint of thumb

Splinted Mallet Finger

4w
Flexor digitorum profundus tendon may be torn directly from distal phalanx or may avulse small or large bone fragment.

. .

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;

XR: Hand series. Look for bony avulsion (EDC) tx

i,

DIPJ extension splint,

inability to actively extend DIPJ

from dorsal base of P3 in bony form of injury

6wk for most injuries 2, Bony mallet with DIPJ

subluxation: consider
PCP vs OR|F

. .

FDP tendon rupture from P3 l\4ech: forced extension

Hx: Forced DIPJ extension, injury; pain

PE: lnability to flex DIPJ

against a flexed finger Tendon retracts variably

XR: Hand series. Look for avulsion fracture from volar base of P3. lVay be retracted to finger/ palm.

Leddy classif ication: Type: 1: to palm. Early repair

.
. .

(-profundus test)

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 of

IMCPJ at

+/-

30' of flexion, palpable mass

$tenor lesion)

XR: Hand; r/o avulslon tx Stress Fluoro: Can compare side to side asym, MR: lf diagnosis is unclear

. .

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
Extensor zones of hand

I ll
Flexor zones of hand
Middle

DIP
PtP

ilt
lV

Proximal phalanx
VI

I-l
T-ll

lP

joint

Proximal phalanx MP joinl

I-lll
-lV

Vll

Dorsal retinaculum

Metacarpal

T-V CMC joint radial styloid

Vlll

Distal forearm

JclrNA"cRA\-"ao

Distal to FDS insertion

il

Single tendon (FDP) injury. Primary repair. DIPJ contracture results if tendon shortened >1cm. Quadriga effect can also result "No man's land," Both tendons(FDs, FDP) require early repair (within 7 days) and mobilization. Lacerations may be at different locaiions on each tendon and away from skin laceration. Preserve A2 & A4 pulleys during repair Primary repair. Arterial arch & median nerve injuries common. Must release & repair the transverse carpal ligament during tendon repair Primary repair (+ any neurovascular injury), Results are usually favorable. Primary tendon repair. Rerupture rate is high.

Finger flexor retinaculum

ilt IV

Palm Carpal tunnel Wrist & forearm

Thumb

Distal to FPL insertion Thumb flexor retinaculum Thenar eminence

Thumb ll

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

Thumb lll

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

DIP joint
il ilt

"Mallet finger." Splint rn extension for 6 wk continuously. Complete lacerations: primary repair and exiension splint. Central slip injury. Splint in extension for 6 wk. lf triangular ligament is also disrupted, lateral bands migrate volarly, resulting in "boutonniere finger" Primary repair of tendon (and lateral bands if needed), then extension splint

Middle phalanx
PIP

joint

ru

Proximal phalanx
MCP joint

often from "fight bite." Repair tendon and sagittal bands as needed
Primary repair and early mobilization/dynamic splinting. Retinaculum likely injured. Primary tendon repair, early mobilization.

VI

l\4etacarpal

vil

Wrisl Distal forearm Proximal forearm

vil
IX

At musculotendinous jxn. Primary repair of tendinous tissue & immobilize 0ften muscle injury Neurovascular injury high. Repair muscle & immobilize,

T90

NETTER,S CONCISE ORTHOPAEDIC ANATOMY

Tendons of flex or digitorum superficial is and profundus

muscles

(Synovial) tendinous

plates (palmar ligaments)

l{ffi i.l'/
C//dda,A

Superficial palmar branch of radial artery and recurrent branch of median nerve to thenar
muscles

UInar artery and nerve Common palmar digital branches of median nerve (cut)
muscles sheath (u lnar bursa)

th finger (synovial) tendinous sheath Common palmar digital

Proper palmar digital arteries and nerves

Annular and cruciform parts of fibrous over (synovial) flexor tendon sheaths
profundus tendon

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

I9I

Hond

lotNTs

Posterior (dorsal) view

Capitate Trapezium Capsule of 1 st carpometacarpal joint Trapezoid

Dorsal carpometacarpal Dorsal metacarpal

4{/

t{ffi

r92

NETTER'S CONCISF ORTHOPAEDIC ANATOMY

lotNnt o Hond
Anterior (palmar) view
Pisiform Hook of hamate Trapezium Palmar carpomelacarpal ligaments Palmar metacarpal ligaments

Joint.uptul"\.
Collateral liSaments

transverse

metacarpal ligaments

plates (palmar lig,aments)

Flexor digitorum / superf icial is tendons (cuf)

';

lexor digitorum profundus tendons

4{tr
rlclilEtl trnHffiilS
..,.,.::

Itllffitfs

Diarthrodial joint. Motion: primarV

flexion & extension; qecondary

r0tation, adduction, abduction

Capsule
collateral

Surrounds joint Center ol metacarpal head to palmar Proximal Phalanx

Secondary stabilizer dorsally Taut in {lexion Primary stabilizer. Taut in flexlon, test in 30' flexion Ulnar Collateral injured in "gamekeeper's/skier s" thumb Taut in extension Test integrity in extension' Primary stabilizer in extension Laxity in extension indicatesiniury t0 volar plate (+/- accessory collateral lig )

Accessory

Palmar to proper collateral

lig.

Volar (palmar)

plate

Palmar metacarpal head to palmar proximal phalanx base

. .

Diarthrodialjoint. Molion: primary = flexion & extenliol Asymmetry of metaearpafhead & collateral ligamenlori
Sunounds joinl Dorsal MC head to palmar

radial & ulnar deviation 0-90"); secondary rssult in 'tam effect" (tight in flexion, lcj:ose in extension) Secondary stabilizer; synovial reflections volar & dorsal

Capsule Proper collateral

Accessory

P1

Primary stabilizer; tight in flexion, loose in extenslon Palmar to proper collaterals; stabilizes the volar plate Limits extension; volar suppon

plate volar (palmar) plate Palmar MC head to palmar P1

collateral
palmar MC head to volar
base Deep transverse Between adlacent metacarpal bases and MCPJ volar Plates

(inte0metacarPal

lnterconnects the volar plates, MCPJs, and metacarpals. Can prevent shortening oJ isolated metacarpal fractures

NETTER,S CONCISE ORTHOPAEDIC ANATOMY

I95

Hond

lotNTs

Flexor digitorum profundus (FDP) tendon

Volar plate of

Cleland's lig..
PIPJ

Flexor digitorum superficialis (FDS) tendon Proximal

Lateral digital sheet

Neurovascular bundle

phalanr
Extensor tendon

Digital a. Digital n.
Crayson's

(P1 )

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

Accessory
col Iateral

Accessory collateral Metacarpophalangeal (MP) joint Proximal interphalangeal

Proper collateral Iigamenl

ioint

{'=* r 'i4f* .***+*'

31i,,,u".n
Palmar
surface

\
Proximal
Phalanges

,Dista

I I

tiEf'vot^,

ptut",

F<,;: :
Distal

/lnterpha langea / rotet loint

ln extension: medial view

Volar

(palmar Iigament)

of "'b'r. . and interphalangeil ' ' li " joints are similar -#

Note: Ligaments
metar arpophalargeal

* t' " *'

:i

ln flexion: medial view

PBOXIMAT INT.FRPHATAI\IGEITL

Capsule
Proper

Sunounds joint Center of

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

collateral
collateral

Pl

head to volar

P2

Primary stabilizer to deviation, Constant tension through ROM Origin volar to axis of rotalion: tight in ext., loose in flexion This can result in a contracture (do not immobilize in flexion) Primary restraint t0 hyperextension. Firm distal attachment, looser proximal attachment (more prone to injury). Checkrein ligaments Often contract after iniury: contracture

Accessory

Volar proximal phalanx head to volar plate (not bone) Volar middle phalanx to volar proximal phalanx (via checkrein ligaments)

Volar (palmar) plate

OTHER IT{IERPHALAJ{GEAL

Capsule Proper

Surrounds joints

Weak stabilizer Similar io PIPJ, constant tension, no "cam effect" Similar to PIPJ, less prone to contracture than PIPJ Primary restraint t0 hyperextension; can be injured

collateral
collateral

B/w adjacent

phalanges
ligaments

Accessory

Volar to collateral Volarly b/w

Volar plate

(palmar)
ligament

phalanges

OTHER STRUCTURES

Grayson's

From flexor sheath to skin; volar to neurovascular bundle From periosteum to

Stabilizes skin & neurovascular bundle lnvolved in Dupuytren's disease/nodules Stabilizes skin during flexion/extension; dorsal to NV bundle

Cleland's

ligament

skin

I94

NEITER,S CONCISE ORTHOPAEDIC ANATOMY

IOINTS
lnsertion of small deep slip of extensor tendon to proximal phalanx and joint capsule
Extensor expansion (hood)

r Hond;

Collateral lig.

Sagittal band Attachment of interosseous m.

to base of proximal phalanx and joint capsule

,gi#

:! :::|N
Volar plate (palmar ligament) Flexor digitorum tendon (cut, Note: Black arrows indicate pull of long extensor tendon; red arrows indicate pull of interosseous and lumbrical muscles; dots indicate axis of rotation of joints.

Lumbrical m

lnterosseous mm

;;;;;#;il; /+
lnsertion of Central band Conjoined lateral

rlrp/

"

lateral ligs Flexor digitorum profundus tendon (cut) plate (palmar ligament)

Finger in flexion: lateral view

Terminal extensor tendon insertion

6ry&4

Metacaruophalangeal Joinl

Flexion

lnterosseous

muscles

Lumbricals

lnsert on proximal phalanx and lateral band (volar to rotation axis) lnserts on radial lateral band (volar to axis 0f rotation

of t\itcPJ)
Sagittal bands insert on volar plate, creating a "lasso" around proximal phalanx base and extend joint through the lasso. EDC has minimal attachment to Pl (which does not extend the joint) but extends joints via the sagittal bands,

Proximal lntenhalangeal Joint

Flexion

Flexor digitorum

(FDS)
(FDP)

superficialis

Flexor digitorum

profundus

Primary PIPJ flexor via insertion on middle phalanx volar base Secondary PIPJ flexor

EDC via the central slip (band)

Lumbricals via lateral bands

Central 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 tendon sheath Lateral bands converge at terminal insertion on dorsal P3 base Links PIPJ & DIPJ extension; extends DIPJ as PIPJ is extended

EDC via terminal extensor

tendon

0blique retinacular ligament

(0RL)

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

I95

Hond

orHER srRucruREs
Lateral bands Extensor Sagittal

lnsertion of central slip of extensor tendon to base of middle phalanx Triangular (aponeurosis) Iigament

expansion

bands

extensor tendon lnterosseous muscles

Posterior (dorsal)

Metacarpal bone Conjoined lateral bands

Lateral slips o{

view
of interosseous tendon passes to base of proximal phalanr and joint capsule

x$%o**
lnsertion of extenso, tundonto base of middle phalanx lnsertion of terminal extensor tendon to base of distal phalanx

long extensor tendon to lateral bands

tendon slip to lateral band

muscle

Central

Oblique
rp

Extensor expansion (hood)

Iut"tul b"nd'

Lateral

Sagiftal bands

Long extensor tendon

bone

Finger in extension: lateral view

muscles

;*:;r;;--

\Lumbrical

muscle

Flexor digitorum profundus tendon Flexor digitorum superf icialis tendon

Dorsal ExtensorAponeurosis

(also called dorsal expansion, dorsal hood, extensor hood)

Extends MCPJ via "lasso" around

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

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 of interossei/lumbricals to form lateral bands

'

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

Lateral Central

'
. .
. .

slip slip
extensor

EDC trifurcates over

Pl

giving two lateral

slips

These slips conjoin with lateral bands Extends PIPJ; torn in boutonniere injury Extends DIPJ via insertion on dorsal base ol P3; avulsed in mallet finger injury
Both join distally to make terminal extensor

Central slip oJ trifurcation; inserts base of Confluence o1 two conjoined dorsal base of distal phalanx

Terminal

tendon

P2 lateral bands on

(P3)

Conjoined lateral band Transverse

Confluence o{ EDC lateral slips and lateral bands from extensor aponeurosis From PIPJ volar plate and flexor sheath to both conjoined lateral bands Transverse bands over P2, connects both conjoined lateral bands and terminal iendon From volar

tendon Prevents conjoined lateral band dorsal subluxation during PIPJ extension Prevents lateral band volar subluxation in PIPJ flexion; torn in boutonniere injury Extends DIPJ when PIPJ is extended

ligamenis

retinacular

Triangular ligament (aponeurosis)

'

0blique

retinacular

Pl to

dorsal P3/terminal

tendon

ligament (ORL)

Tendinous connections between ECD tendons to adjacent fingers proximal to MCPJ

Prevents full extension of finger when adjacent digit is flexed (see page 1 55)

196

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

OTHER STRUCTURES O HONd

Tendinous sheath of flexor pollicis longus (radial bursa) Common flexor sheath (ulnar bursa) Tendinous sheath of flexor pollicis longus (radial bursa) Flexor digitorum profundus tendons Tendinous
sheath of flexor

fhenar space Midpalmar

space

pollicis longus
(radial

Common flexor sheath (ulnar bursa)

Lumbrical (in fascial

sheaths)

Synovial tendon sheaths of fingers

Fascia of adductor pollicis

Flexor digitorum superficialis tendons

Thenarspace

-..'.-

flexor sheath (ulnar bursa) (opened) Lumbrical muscles in fascial sheaths

(deep to flexor tendon and lst lumbrical muscle) (Synovial) tendinous sheath of finger Lumbrical muscles in fascial sheaths (cut and reflected)

Midpalmar space
(deep to flexor tendons and lumbrical muscles)

Fibrous and synovial (tendon) sheaths of finger (openea) Flexor digitorum superfi cialis tendon (FDS) Flexor digitorum profundus tendon (FPS)

Ll."

]ilffi
Midpalmar
Palmar

Common palmar digital artery and nerue Lumbrical muscle in its fascial Flexor tendons to 5th digit in common flexor sheath (ulnar Hypothenar musc

Prolundus and superficiali' ilexor tendons to 3rd digit betrveen midpalmar and thenar spaces space Flexor pollicis longus tendon in tendon sheath (radial bursa)

pollicis
longus tendon

pollicis muscle
Palmar interosseous fascia

Dorsal interosseous

Palmar interosseorrs mrrscles Dorsal interosseous muscles xtensor lendons

NETTER'S CONCISE ORTHOPAEDIC ANATOMY T97

Hond

OTHER STRUCTURES
Epiphysis

membrane

Nail matrix

Sagittal section
Eponychium (cutic il he.l (sterile matrir) Na

(germinal Nail

Articular cartilage Middle phalanx

Extensor digitorum tendon

Lunula

digitorum superficialis tendr

Body of nail

Distal phalanx

Fibrous tendon
sheath finger

al (flexor tendon) sheath finger

I Nerves Arteries Septa

Distal anterior closed space (pulp)

digitorum profundus tendon

I

Palmar ligament (plate)

Articular cavity
Body of nail

Cross section

Nail bed
Distal phalanx Fibrous septa and areolar tissue in anterior closed space (pulp)

through distal
phalanx

Dorsal branches of proper palmar

digital arteries and nerves to dorsum of middle and terminal phalanges

Dorsal digital artery and nerye

Arteries and nerves

4{Y;
Nutrient branch to epiphysis
Nutrient branches to palmar digital artery

metaphysii

Proper palmar digital artery and nerue

T98

NFTTER,S CONCISE ORTHOPAEDIC ANATOMY

Thumb CMC lnjection

Digital Block

Digital block, both

sides of base of

finger

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 smaller needle, and insert into joint (if available use an image intensifier to confirm needle is in joint). Aspirate t0 ensure needle is not in a vessel. lnject 1 -2 ml of 1:.1 local (without epinephrine) /corticosteroid preparation into CMC joint. fhe fluid 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 corticosteroid 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

NETTER,S CONCISE ORTHOPAEDIC ANATOMY

I99

Hond

HtsroRY
Boxer fracture
Fractures of metacarpal

Fractures and dislocations of thumb

tnjury to proximal phalanx or metacarpophalangeal joint of thumb caused by fall with outstretched hand on ski pole

neck commonly result from end-on blow of fist. Often called street-fighter or boxer fractures

Fight bite
Penetration of metacarpophalangeal joint by tooth in fist fight

Mallet finger

ft
1. Hand
2.

{r

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

dominance Right or Ieft Age Young

Acute Chronic CMC (thumb)

Dominant hand injured more often Trauma, infection

Middleage-elderly

Arthritis,nerveentrapments

3. Pain a. onset
b. Location

Trauma, infection

Joints (MCPS, lPs)

Volar (fingers)

Arthritis Arthritis (0A) especially in women Arthritis (osteoarthritis, rheumatoid)

Purulent tenosynovitis (+ Kanavel signs) Rheumatoid arthritis Trigger finger lnfection (e.9., purulent tenosynovitis, felon, paronychia) Trigger finger, arthritides, gout, tendinitis Ganglion, Dupuytren's contracture, giani cell tumor

4.

Stiffness

ln AM,

Catching/clicking
After trauma No trauma

"catching"

Fall, sports injury

0pen wound

Fracture, dislocation, tendon avulsion, ligament injury lnfection Trauma (e.9., fracture, dislocation, tendon or ligament injury) Nerve entrapment (e.9., carpal tunnel), thoracic ouflel syndrome, radiculopathy (cervical) Nerve entrapment (usually in wrist or more proximal)

8. Activity 9. Neurologic

Sports,

mechanical

symptoms

Pain, numbness, tingling Weakness

10' Historyof

arthritides

Multiple

jointsinvolved

Rheumatoidarthritis,Reitefssyndrome,etc.

2OO NETTER,S CONCTSE ORTHOPAEDIC ANATOMY

PHYSICAL EXAM
Rheumatoid arthritis Boutonniere deformity of index finger with swan-neck deformity of other fingers

Hond

Osteoarthritis
Heberden's nodes seen in index and middle finger distal interphalangeal joints. Bouchards nodes seen in proximal interphlangeal joints of the ring and

smallfinger

Rotation displacement of ring finger. All fingers should point toward scaphoid when clenched

Median nerve compression Atrophy of thenar muscles due to compression of median nerve

Gross

deformity

Ulnar drift/swan neck, Rotational or angular

deformity etc

boutonniere

Rheumatoid arthritis Fraciure Dupuytren's contracture, purulent tenosynovitis Fracture (acute), fracture malunion Neurovascular disorders: Raynaud's, diabetes, nerve rnlury

Finger

position
changes

Flexion Rotation of digit

Cool, hairless, spoon,
DIPS

Skin, hair, nail

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

Bouchard's nodes (at PlPs) Rheumatoid arthritis Purulent tenosynovitis Median nerve injury, CTS, CB/|1 pathology Ulnar nerve injury (e.9., cubital tunnel syndrome)

PlPs MCPs

Fusiform shape finger Thenar eminence Hypothenar eminence/intrinsics

NETTER'S CONCISE ORIHOPAEDIC ANATOMY

2OI

Hond

PHYSIcAL ExAM
Stenosing tenosynovitis (trigger finger)

ffi ffi w@il

ffig

lnfections of the fingers

W
wffit

Paronychia

Felon

4 ff87 4 t'/
Patient unable to extend affected finger. lt can be extended passively, and extension occurs with distinct and painful snapping action. Circle indicates point of tenderness where nodular enlargement of tendons and sheath is usually palpable

Purulent tenosynovitis. Four cardinal signs of Kanavel

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

4. Tenderness along tendon sheath

Warm, red Cool, dry

Infection Neurovascular compromise

Metacarpals
Phalanges and finger

Each along its

length

Tenderness may indlcate fracture Tenderness: f racture, arthritis Swelling: arthritis Wasting indicates medjan nerve injury Wasting indicates ulnar nerve injury Nodules: Dupuy,tren s contracturei snapping 41 pulley with finger extension: trigger finger Tenderness suggests purulent tenosynovitis Tenderness: paronychia or felon

joints

Each separately

Thenar eminence Hypothenar eminence Palm (palmar fascia) Flexor tendons: along volar finger AII aspects of finger tip

202

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

PHYSICAT

ExAM

Hond

Ulnar
deviation

J6FINA.RAK,J^6
I

Range of thumb opposition

Normal finger flexion is composite of flexion of MP, PlP, and DIP joints and allows fingertip to touch distal palmar crease

Normal thumb is composite of movemens of CMC, MP, and lP joints. Normal range is to base

opposition

NETTER'S CONCISE ORTHOPAEDIC ANATOMY 2O3

Hond

PHYSIcAL EXAM
Sensory testing

Median nerve C5-Tl

Ulnar nerve

CB-T1

Radial nerve CS-CB

Sensory distribution

Sensorydistribution

Sensorydistribution

Two-point discrimination

Motor testing

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

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

Finger extension. EDC. Radial nerve

Finger abduction. Interosseous m. Ulnar n. T1

(PrN). C7

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

204

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

PHYstcAt EXAM

Hond

\fiv,iltr
JBITNA.cRA\..ao
Elson test When pinching a piece of paper between thumb
and index finger, the

x{Y

Normal intact central slip

thumb lP joint will flex if the adductor pollicis

muscle is weak (ulnar nerve paralysis).

Thumb instability test

for ruptured ulnar collateral ligament of thumb (gamekeeper thumb)
Stress test

Abnormal ruptured central slip

test Sublimus test

Profundus Froment's

Stabilize PIPJ in extension, flex DIPJ

only Extend all fingers, flex a single finger at PIPJ

Hold paper with thumb and index finger, pull paper

lnability to flex DIP alone indicates FDP pathology lnability to flex PIP of isolated finger indicates FDS pathology lf thumb lP flexion is positive, suggest adductor pollicis weakness and/or ulnar nerve palsy Pain indicates arthritis at CIVC joint of thumb

sign test

CMC grind Finger ity

Axial compress and rotate CMC

j0int
valgus

test Thumb instability test test Elson test

instabil-

Stabilize proximal joint, apply varus and stress

Laxity indicates collateral ligament injury

Stabilize MCB apply valgus stress in extension and 30'of flexion

Laxity at 30": ulnar collateral ligament injury Laxity in extension: accessory collateral ligament and/or volar plate injury Tight or inability t0 flex PIPJ, improved with MCPJ flexion indicates tight intrinsic muscles

Bunnell-Littler

Extend MCPJ, passively flex

PIPJ
exten-

Flex PIPJ

sion

90'over

table edge, resist P2

DIPJ rigidly extending (via lateral bands) indicates

central slip injury (boutonnidre)

NEITER S CONCISE ORTHOPAEDIC ANATOMY 205

Hond

oRtctNs AND tNsERnoNs

lexor pollicis brevis

Abductor pollicis Abductor pollicis Opponens pollic Flexor carpi r Abductor brevis Flexor poll brevis Flexor pollicis longus

Flexor carpi ulnaris

digiti minimi
Flexor digiti minimi brevis carpi ulnaris Muscle attachments lI Origins I lnsertions

digiti minimi

Volar interossei
Abductor digiti minimi lexor digiti minimi brevis

Adductor Oblique
Iransverse head Flexor digitorum superf icial is Flexor digitorum profundus
Extensor carpi radialis brevis Extensor carpi

radialis brevis

Palmar view

Extensor carpi

Abductor pollicis
longus

ulnaris

1ff,ffi 4,t'/
Extensor digitorum communis (central slip)

Extensor digitorum communis (terminal tendons)

Dorsal vieri,

Trapezium Abductor pollicis brevis

Flexor pollicis brevis 0pponens pollicis

Dorsal interosseous Palmar interosseous Adductor pollicis Abd. pollicis longus

Proximal phalanx
Ext. pollicis brevis (thumb)

Proximal phalanx Abductor pollicis brevis (thumb)

Flexor pollicis brevis (thumb) Adductor pollicis (thumb) Palmar interossei Flexor digiti minimi brevis Abductor digiii minimi

Dorsal interossei Abductor digiti minimi

Capitate
Adductor pollicis

Hamate Flex. digiti minimi brevis 0pponens digiti minimi Pisilorm Abductor digiti minimi

0pponens pollicis 0pp. digiti minimi Flexor carpi radialis

Flexor carpi ulnaris Ext. carpi rad. longus Ext. carpi rad. brevis Extensor carpi ulnaris

Middle phalanx Extensor digitorum communis (central slip)

Distal phalanx
Ext. pollicis longus

Middle phalanx
Flexor digitorum superficialis

(thumb) Extensor digitorum communis (terminal tendon)

Distal phalanx
Flexor pollicis longus (thumb) Flexor digitorum profundus

206

NEI TER S CONCISE ORTHOPAEDIC ANATOMY

MUSCTES
Anterior (palmar) view
Radial artery and palmar carpal branc
Ra

Hond

Pronator quadratus muscle Ulnar nerve Ulnar artery and palmar carpal branch Flexor carpi ulnaris tendon lmar carpal arterial arch form

Superfieial palmar branch o[ radial artery

Transverse carpal ligamenl (f leror retinacu lu m ) lref I ected)

Opponens pollicis muscle

Branches of median nerve to thenar muscles and to 1 st and 2nd lumbrical muscles

Abductor pollicis
brevis muscle lcut) Flexor brevis muscle

digiti minimi muscle lcut) Deep palmar branch of ulnar artery and deep branch of ulnar nerve digiti minimi brevis muscle (cut)
Opponens digiti minimi muscle Deep palmar (arterial) arch metacarpal arteries

Adductor
muscle
st dorsal interosseous muscle
1

palmar digital arteries

transverse metacarpal ligaments

Branches from deep branch of ulnar nerve to 3rd and 4th lumbrical muscles and to all interosseous muscles

Lumbrical riuscles trel/ected)

NETTER,S CONCISE ORTHOPAEDIC ANATOIVIY

207

Hond

MUscLEs
Lumbrical muscles

1 st (un

and 2nd lumbrical ipennate)

3rd and 4th lumbrical muscles (bipennate)

Flexor digitorum superficialis tendons (cut)

lnterosseous muscles Posterior (dorsal) view

Palmar interosseous muscles (unipennate) Deep trdnsverse metacarpal ligaments

Radius
Radial Abductor digiti m tnlmt

arterv '

Abductor

pollicis

brevis muscle Dorsal

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

interosseous

4{ffi rT\/
&2

extensor expansions
(hoods)

Lumbricals 1

FDPtendons (radial 2) FDPtendons (medial 3)

Radial lateral bands Radial lateral bands Proximal phalanx and extensor expansion (lat-

Lumbricals3&4

flex l\4CP Ulnar Extend plp flex -i;H -'

l\4edian
Extend PlP, Digit
MCP

Only muscles in body to insert on their own antagonist (FDP) Palmar to deep lransverse lVlC ligaments.
DAB: Dorsal ABduct

abduction

flexion

Bipennate: each belly has separate insertion

eral bands)

lnterosseous: Adjacent Fxtensor expan- Ulnar palmar (PlO) metacarpals sion (lateral
bands)

Digit

adduction

pAD: palmar ADduct Unipennate

208

NETTER,S CONCISE ORTHOPAEDIC ANATOMY

Thenar compartment

l)orsal inc:ision

Dorsal interosseous compartments

Transverse

Carpal tunnel
release

carpal Iigament

4ftr

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

209

Hond

NERVES

Cutaneous innervation of the hand

Anterior (palmar) view Medial cutaneous nerye of forearm

Flexor pollicis brevis muscle (deep head only; superficial head and other thenar mus-

Palmar' M"diun

""*"

I Palmar/
branch

digital branches

4.\'/

{ffi

Adductor

ffJ5:

Common palmar digital nerve CommunicatinB branch of median nerve with ulnar nerve Proper palmar digital nerves (dorsal digital nerves are from dorsal branch)
I branches to dorsum of middle and distal phalanges

i}ltfiiili.{llli.,,.l

ii:::'-1aLi1*::,?i
.r::it:1._r,.,its':!:,ii..:t1il

:,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. This nerve 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 hamate and runs with the deep arterial arch, The superficial branch continues into the palmar aspect of the fingers as the palmar digital nerves. Sensory: Dorsal ulnar handt via dorsal cutaneous branch Dorsal small & ring fingers: via dorsal digital branches Ulnar proximal palm: via palmar cutaneous branch Ulnar distal palm: via common palmar digital branches Palmar small & ring fingers: via proper palmar digital branches

Motor:

"

Superficial(sensory)branch Palmaris brevis-only muscle innervated by this branch

Deep (motor) branch: travels with deep arterial arch . Hypothenar compartment

Opponens digiti minimi (0Dl\4) Adductor compartment " Adductor pollicis lntrinsic muscles Lumbricals (ulnar two B,4l) Dorsal interossei (Dl0) " Palmar (volar) interossei (Vl0)

. .

Abductor digiti minimi (ADM) Flexor digiti minimi brevis (FDMB)

"

. .

o Thenar compartment Flexor pollicis brevis (FPB|--deep head only

2IO

NETTER S CONCISE ORTHOPAEDIC ANATOMY

NERVES
Posterior (dorsal) view

T HONd

Medial cutaneous:
nerve of forearm Division between ulnar \ and radial n.ru. inn"rua- | tion on dorsum of hand is I variable; it often aligns withf middle or 3rd digit instead I of 4th digit as shown ,,1
l-

r MusculoLateral cutaneous I ." > cutaneous nerve ot torearm I / nerve

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

Wrist and Hand: Superficial

Radial Dissection
Lateral (radial) view Superficial branch radial nerve

$ branches

Medial branch
Lateral branch
digita
I

I
Ulnar

Dorsal cutaneous'l branch and clorsal

nerve

] -. I properpalmar/ I digital branches

Abductor pollicis
l:

digital branches

Proper

palmar I

digital branches

Median nerve

branches of radial nerve

Opponens pollic

n::n,

Superficial head. \ of flexor pollicis brevis (deep head supplied by ulnar nerve) Ji
st and 2nd lumbrical
1

almar cutaneous branch ting branch of median nerve with ulnar nerve Common palmar digital
nerves Proper

carpal branch of radial a rtery

muscles

4{w

Dorsal branches to dorsum of middle and distal phalanges

palmar digital
neryes

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 branch Volar thumb, lF, MF, radial RF: via palmar digital branches Dorsal 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 that supply the dorsal hand & thumb web space, They continue as dorsal digital branches to the dorsal fingers. Sensory. Dorsal radial handr via superficial branch Dorsal proximal thumb, lF, MF, radial RFr via dorsal digital branches

Motor:

None (in hand)

NETTER,S CONCISE ORTHOPAEDIC ANATOMY

2II

Hond

ARTERIES
UInar artery and nerve

Superficial palmar branch of radial arterv Recurrent (motor) branch of median nerve to thenar muscles

carpal ligament (flexor retinaculum) Deep palmar branch of ulnar artery and deep branch of ulnar nerve ial branch of ulnar nerve ommon ilexor sheath (ulnar bursa) Superficial palmar (arterial) arch palmar digital nerves and arteries Communicating branch of median nerve with ulnar nerve Proper palmar digital nerves and arteries
Branches of proper palmar digital nerves and arteries to dorsum of

Adductor pollicis
muscle Proper digital nerves and arteries to thumb
Branches of medi nerve to 1 st and 2nd

Iumbrical muscles

middle and distal phalanges

4{ff
Princeps pollicis Proper digital arteries and
nerves of

lnar artery and nerve Radial artery Superficial palmar branch of radial Deep palmar (arterial) Palmar carpal branches of radial and ulnar arteries 'Deep palmar branch of ulnar artery and deep branch of ulnar nerve to hypothenar muscles hranch

Distal limit of superficial palmar arch (Kaplan's line) Radialis indicis Palmar metacarpal Common palmar digital Proper palmar digital Proper palmar digital nerves from median nerve

of ulnar nerve
Deep palmar branch of ulnar nerve to 3rd and

4th lumbrical, all inter

osseous, adductor pollicis,

and deep head of flexor pollicis brevis muscles 'Proper palmar digital nerves from ulnar nerve

2T2

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

DISORDERS
Osteoarthritis
Rheumatoid arthritis

o Hond

Section through distal interphalangeal joint shows irregular, hyper plastic bony nodules (Heberden's nodes) at articular margins of distal phalanx. Cartilage eroded and joint space narrowed

Radiograph of distal interphalangeal

ioint reveals Iate-stage degenerative

changes. Cartilage destruction and margi nal osteophytes (Heberden's nodes)

Radiograph shows cartilage thinning at proximal interphalangeal joints, erosion of carpus and wrist ioint, osteoporosis, and finger deformities

Late-stage degenerative changes in carpometacarpal articulation of thumb

Boutonniere deformity of index finger with swan-neck deformity of other fingers

. .

. .

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/activity PE: Nodule/deformity, tenderness, decreased R0lvl

XR: 0A findings: joint space loss, osteophytes, sclerosis, subchondral cysts

1. NSAIDS 2. Steroid injection 3. Arthrodesis/fusion 4. Afthroplasty

Ganglion cyst from arthritic

Hx: l\4ass near a joint

PE: Mass,

XR: Joint arthritis

joint (DIPJ #1)

+/-

tenderness

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 destruction LABS: RE ANA, ESR,

CBC, uric acid

1. Medical management 2, Synovectomy (1 joint) 3, Tendon transfer/repair 4. Arthrodesis/arthroplasty

FDS insertion/volar plate injury

Hx

lnjury or RA

XR: Shows bony deformity

1. Early: splint

Traumatic or assoc. with RA Lateral bands subluxate dor sally, hyperextends PIPJ

PE: Deformity: flexed DIPJ,

injury hyperextended PIPJ

2. Late: surgical release and reconstruction

3, Arthrodesis

. .

Central slip (EDC) and triangular ligament injury Traumatic or assoc. with RA Lateral bands subluxate volarly, hyperflexes PIPJ

Hr

Traumatic injury or RA

PE: Deformity: flexed PIPJ, +

XR: Shows bony deformity

1. Early: splint PIPJ in

extension

Elson's test (inability to extend the flexed PIPJ)

2. Reconstruct lateral
bands and central slip 3. Arthrodesis/arthroplasty

NETTER,S CONCISE ORTHOPAEDIC ANATOMY

2I5

Hond

DISoRDERS
Paronychia infection

Tenosynovitis

4{tr
Sporotrichosis
Tenosynovitis of the middle finger. Treated with zigzagvolar incision. Tendon sheath opened by reflecting cruciate pulleys Fine plastic catheter inserted for irrigation. Lines of incision indicated for tendon sheaths of other fingers (A); radial and ulnar bursae (B); and Parona's subtendinous space (C)

tu re
FreA

fs

Eponychium elevated from nail surface

Horseshoe abscess

ffiffi
W.4

#
W W

W
Begins as small nodule and spreads to hand, wrist, forearm (even systemically). From focus in thumb spreads through radial and ulnar bursae and tendon sheath of little finger, with rupture into Parona's subtendinous space

Felon

. .

Tendon sheath infection Usu, from puncture/bite May spread proximally lnto deep spaces or Parona's space (horseshoe abscess)

Hx: Pain and swelling

PE: Kanaval signs (4): 1, Flexed position

XR: Plain films. r/o

foreign body, air

LABS: CBC, ESR, CRP

2, 3. 4.

Fusiform swelling Pain w/passive extension Flexor sheath tenderness

1. Diagnosis <24hr: lV antibiotics, close observation (l&D if no improvement) 2, Diagnosis >24hr: trriga-

lion and debridement of sheath + 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 release septum in pulp)

2. Antibiotics (lV vs oral)

. #l hand infection . Etiology: nail biting,

nails

lnfection of nail fold hang

Hr

Pain & swelling PE: E$hema, tenderness, +/- drainage

XR: Usually not needed

1. Early: warm soaks 2. l&D and oral antibiotics 3. Partial nail excision

Infection in deep spaces or tissues (e.9., thenar, hypothenar, Parona's [horseshoe])

Hx: Pain & swelling PE: Edema, erythema, tenderness, fluctuance, +/- drainage

XR: Usually normal MR/CT May help if diagnosis is unclear

1. lncise & drain, lV abx 2. Wound care/dressing changes as needed

.
.

Fungal (Sporothrix s.)infection from plants/roses Spreads via lymphatics

Hx

Rash/discoloration

Potassium iodine solution

PE: Early: single nodule

Late: multiple nodules/rash

2I4

NETTERS CONCISE ORTHOPAEDIC ANATOMY

DISORDERS
Deep space infections

o Hond

lnfection of midpalmar space secondary to tenosynovitis of middle iinger. Focus is infected puncture wound at distal crease. Line of incision indicated

Infection of thenar space from tenosynovitis o{ index finger due to puncture wound.

Dupuytren's
Disease

4.t'/

*{ffi

Partial excision of palmar fascia with care to avoid neurovascular bundles

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

. Usually dominant hand . "Fight bite": fist to mouth #l

.
Bacteria: Strep., Staph. a. Human: Eikenella corr. Animal. P a steu 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

1.

Td & rabies prophylaxis if indicated

2. l&D, wound care 3, lV antibiotics (ampicillin/

sulbactam)

[ABS: CBC, ESR, CRP

.
r

lil;llWrffi
Tighvthickened 41 pulley entraps flexor tendon Associated with DM, RA, age Congenital form in pediatrics Hx: 40+, pain, snapping or locking (esp. in AM)
PE: Tender flexor sheath,

Fill},'t,,'$,l'"" ""'
XR: Usually normal MR: Not needed, PE is diagnostic 1. Splint, occupational rx

2. Corticosteroid injection
into tendon sheath 3. A1 pulley release

snapping with flex./ext.

Contracture of palmar fascia ibroblasts create thick cords of type lll collagen Associated with northern Europeans (AD), DM, EtoH
lVyof

Hx: Usually male, 40+, c/o hand mass PE: Nodule in palm, +/-

XR: Usually normal MR: Not needed if diagnosis is clear. May be useful if etiology of mass is unclear.

1, Early (mass, no contracture): reassurance 2. Late (contracture): surgical excision of cords

coniracture of MCPJ or
PIPJ

1ii,ii:ii111i11ili,.:,!:i:i,:
Hx
Small volar mass PE: Firm, "pea"-size nodule, does not move

,,,,,,,,,.,,,,
1.

Ganglion-type cyst of the flexor tendon sheath Most common hand mass

XR: Usually normal MR: Not needed

Aspiration/puncture

2. Surgical excision if recurrent

Wtendon

l
t\

NETTERS CONCISE ORTHOPAEDIC ANATOMY 2T5

r
5
t

tr"d .

prorRrRrc DrsoRDERs

ti{ tl I

t
I,r

&

a tl
*
Incision lines

ir

(prefered method)
Dorsal aspect
Palmar aspect

J
iil

,'

. . .

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 connected PE: Fingers are connected either to tip or incompletely down the

finger
XR: Will determine if bones are fused (complex)

1. Should wait approximately 1yr. tllen surgically separate fingers 2. Careful incision planning and skn qrafts 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 tvpically normal

1 . Nonoperative: stretching, splint 2. Functionally debilitating contrac-

ture : surgical

relemltendon

transfer

. . .

Deviation of finger in coronal plane Radial deviation of small finger #1 Etio: delta-shaped middle phalanx

Hx/PE: Deviation of finger, cosmetic and functional complaints XR: Shows delta-shaped middle phalanx

l.

i 'v Mild: no freatrnent !

I

2. Functional deficit surgical conectior/realignment osteotomy

:;

2T6

NETTER,S CONCISE ORTHOPAEDIC ANATOMY

t;r
I

t: ,t

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 thumb XR: Will show bifid or extra phalanges depending on which type of duplication

1. Surgical reconstruction to

obtain stable thumb. Generally, retain ulnar thumb/ structures & reconstruct radial side (e.9,, type 4)

Partial or complete absence of

. Blauth classrfication: Types l- V . Treatment based on presence of . .

CMC joint

thumb

Hx/PE: Small to completely absent thumb XR: Range of small, shortened, or absent bones (phalanges, metacarpal, trapezium) Evaluate for presence of the CMC joint

l: Small thumb: no treatment 2. Types ll-lllA: Reconstruction

1. Type 3. Types lllB-V (no CMCJ): amputation & pollicization

Associated with some syndromes

Constrictive bands lead to digit necrosis or diminished growth/ development, Nonhereditary

Hx/PE: ShoMruncated fingers with bands at level of diminished growth XR: Small, shortened, or absent phalanges

1. Complete amputations if needed

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

coverage

NETTER'S CONCISE ORTHOPAEDIC ANATOMY

2I7

Hond o

SURGICAL APPRoACHES
Volar approach to finger

Midlateral approach to finger

Flexor
sheath

Joint ligaments
F

J&HNA,RA\**o

digitorum superficialis Flexor digitorum profundus lexor tendons

. . .

Flexor tendons (repair/explore) Digital nerves Soft tissue releases lnfection drainage

. Digital artery . Digital nerve . Flexor tendon

.
.

l\4ake a "zigzag" incision connecting

finger creases
Neurovascular bundle is lateral to the tendon sheath.

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

2I8

NETTER'S CONCISE ORTHOPAEDIC ANATOMY