SURGICAL ANATOMY OF THE HAND AND UPPER EXTREMITY part 06

 

ches to the hand compartments. A: Approach to the hypothenar

compartment. B: Approach to the lumbrical, central palmar, and adductor compartments.

C: Approach to the thenar compartment. D, E: Approach to the interosseous compartments.

proximal palmar crease, and the central space of the hand

may be approached through an incision at the thenar crease.

A more comprehensive approach that begins in the proximal palm and zig-zags distally allows access to the lumbrical and central compartment as well as the adductor compartment. Digital fasciotomies are made through mid-axial

incisions positioned on the side of the digit that is less used

in everyday activities. The index, long, and ring fingers may

be opened on the ulnar aspect and the small finger and

thumb on the radial aspect. The plane of dissection is dorsal to the neurovascular bundles and palmar to the flexor

sheath, and the dissection is carried across the digit to

release all portions of the compartment.

ANATOMIC VARIATIONS

Nerve

Cannieu-Riche Anastomosis

This anastomosis, in its classic form, is between the motor

branch of the ulnar nerve and the motor branch of the

median nerve in the proximal and radial palm (163). It was

described by Cannieu in 1896 and 1897 and by Riche in

1897 (164–166).

Anatomy

The classic description is of an anastomosis between a

ramus of the recurrent branch of the median nerve supplying the superficial head of the FPB and the anastomotic

ramus of the deep branch of the ulnar nerve supplying the

deep head of the FPB (Fig. 10.82). The anastomotic branch

is present between the two heads of the adductor pollicis

and then circles round the FPL tendon on its lateral side.

Variations

Anatomists who have studied this anastomosis have identified the following variations (Fig. 10.83):

1. A separate branch of the median nerve to the superficial

head of the FPB may send a branch to the anastomosis;

in this type, the anastomosis can be located either on the

surface of or deep in the FPB.

2. The anastomosis may be with one or two digital nerve

branches of the thumb from the median nerve, and in

this type the anastomosis is located medial to the tendon

636 Regional Anatomy

FIGURE 10.82. Cannieu-Riche anastomosis. A, Recurrent branch, median nerve; B, digital branch

to thumb; C, branch to deep head, flexor pollicis brevis; D, branch to adductor pollicis; E, anastomosis.

of the FPL, and sometimes a double or triple anastomosis may be found.

3. An anastomosis may occur between one of the branches

of the digital nerve to the thumb and the branch to the

adductor pollicis, coming from the deep ulnar nerve;

this anastomosis is medial to the FPL tendon and deep

in the adductor pollicis, and there is no ulnar innervation to the deep head of the FPB.

4. A deep branch of the ulnar nerve may pass through and

innervate the first lumbrical on its way to anastomose

with the digital branch to the index finger (163).

Incidence

In a study of the incidence of this anastomosis, 27 of 35

hands (77%) had a Cannieu-Riche anastomosis between

the median and ulnar nerve (163). Thirteen of the 27 hands

with the anastomosis demonstrated the anastomotic ansa

that circled around the lateral side of the FPL tendon as

described by Cannieu in 1897 (165). In the remaining 14

hands, the 4 variations mentioned previously were noted,

and in all of these the anastomosis lay medial to the FPL

tendon.

Clinical Significance

The FPB, in addition to its classic anatomic ability to flex

the MCP joint, also can abduct and pronate the first

metacarpal (167,168). Double (from median and ulnar)

innervation of the FPB muscle may explain a nonanatomic

persistence of function after median or ulnar nerve injury.

Adequate pinch may be retained and Froment’s sign may be

minimal or absent in the ulnar nerve–injured patient if the

deep head of the FPB has median nerve innervation; in

median nerve injury, opponensplasty may not be required if

the superficial head of the FPB is ulnar nerve innervated

(167).

Neural Loop of the Deep Motor Branch of the

Ulnar Nerve

A branch from the main motor component of the ulnar

nerve has been identified at the distal end of Guyon’s canal

as the nerve passed around the hook process of the hamate

(Fig. 10.84). The aberrant branch was noted to arise proximal to the hook process of the hamate and to rejoin the

nerve distally deep in the palm. This configuration was

noted in three cases of neurolysis of the ulnar nerve in

10.1 Palmar Hand 637

FIGURE 10.83. Variations of the Cannieu-Riche anastomosis. 1,

Ulnar nerve; 2, median nerve; 3, beep branch of ulnar nerve; 4,

branch to adductor pollicis; 5, branch to deep head of flexor pollicis brevis (FPB); 6, recurrent branch; 7, digital branch to thumb;

8, separate branch of median nerve to superficial head of FPB; 9,

digital branch to index finger.

FIGURE 10.84. Neural Loop of the deep motor branch

of the ulnar nerve.

Guyon’s canal. Based on these operative findings, an

anatomic study was performed that revealed 7 cases (1 case

was bilateral) in 77 cadavers, for an incidence of 9% (169).

Clinical Significance

The authors of this report noted that this variation should

be considered when there is an atypical presentation after

penetrating injuries or compression neuropathy of the ulnar

nerve at the wrist. In addition, knowledge of this configuration is of value during decompression of Guyon’s canal or

excision of a nonunited fracture of the hook process of the

hamate (169).

Muscle

Palmaris Brevis Profundus

This is an anomalous muscle that courses transversely from

the flexor retinaculum and palmar fascia to the fascia in the

region of the pisiform. It is a thick muscle belly, parallel and

deep to the palmaris brevis. The muscle may lie between the

superficial and deep branches of the ulnar nerve.

Clinical Significance

This muscle may compress one or both segments of the

ulnar nerve in the region of Guyon’s canal and cause ulnar

neuropathy. It may represent a form of duplication of the

normal palmaris brevis (170).

REFERENCES

1. Williams PL. Gray’s anatomy, 38th ed. New York: Churchill Livingstone, 1996.

2. McGrouther DA. The microanatomy of Dupuytren’s contracture. Hand 14:215–236, 1982.

3. Riordan DC, Kaplan EB. Surface anatomy of the hand and

wrist. In: Spinner M, ed. Kaplan’s functional and surgical

anatomy of the hand, 3rd ed. Philadelphia: JB Lippincott, 1984:

353–362.

4. Popich GA, Smith DW. The genesis and significance of digital

and palmar hand creases: preliminary report. J Pediatr 77:1017,

1970.

5. Bugbee WD, Botte MJ. Surface anatomy of the hand: the relationships between palmar skin creases and osseous anatomy.

Clin Orthop 296:122–126, 1993.

6. Kaplan EB. Functional and surgical anatomy of the hand, 2nd ed.

Philadelphia: JB Lippincott, 1965.

7. Hollister A, Giurintano D. How joints move. In: Brand PW,

Hollister A, eds. Clinical mechanics of the hand, 2nd ed. St.

Louis: Mosby-Year Book, 1959:35–59.

8. Imaeda T, Kai-Nan A, Cooney WP III, et al. Anatomy of

trapeziometacarpal ligaments. J Hand Surg [Am] 18:226–231,

1993.

9. Aune S. Osteo-arthritis in the first carpo-metacarpal joint. Acta

Chir Scand 109:449–456, 1955.

10. Pellegrini VD Jr. Osteoarthritis of the trapeziometacarpal joint:

the pathophysiology of articular cartilage degeneration. I.

Anatomy and pathology of the aging joint. J Hand Surg [Am]

16:967–974, 1991.

11. Bettinger PC, Linscheid RL, Berger RA, et al. An anatomic

study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint. J Hand Surg [Am] 24:786–798, 1999.

12. Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis: staging as a rationale for treatment. Hand Clin 3:445–469, 1987.

13. Cooney WP, Chao EYS. Biomechanical analysis of static forces

in the thumb during hand function. J Bone Joint Surg Am 59:

27–37, 1977.

14. Eaton RG, Littler JW. Ligament reconstruction of the painful

thumb carpometacarpal joint. J Bone Joint Surg Am 55:

1655–1666, 1973.

15. Glickel SZ, Barron OA, Eaton RG. Dislocations and ligament

injuries. In: Green DP, ed. Operative hand surgery, 4th ed. New

York: Churchill Livingstone, 1999:772–808.

16. Shaw SJ, Morris MA. The range of motion of the metacarpophalangeal joint of the thumb and its relationship to injury.

J Hand Surg [Br] 17:164–166, 1992.

17. Bowers WH, Wolf JW Jr, Nehil JL, et al. The proximal interphalangeal joint volar plate: I. an anatomical and biomechanical study. J Hand Surg[Am] 5:79–88, 1980.

18. Agur AMR, Lee MJ. Grant’s atlas of anatomy, 10th ed. Philadelphia: Lippincott Williams & Wilkins, 1999.

19. Watson HK, Dhillon HS. Stiff joints. In: Green DP, ed. Operative hand surgery, 3rd ed. New York: Churchill Livingstone,

1993:549–562.

20. Gagnon S, Botte MJ, Zinberg EM, et al. Anatomy of the palmar plates: comparative morphology and motion characteristics. Adv Biomech Hand Wrist 85–92, 1994.

21. Tubiana R, Thomine J-M, Mackin E. Movements of the hand

and wrist. In: Tubiana R, Thomine J-M, Mackin E, eds. Examination of the hand and wrist. St. Louis: Mosby, 1996.

22. Dray GJ, Eaton RG. Dislocations and ligament injuries in the

digits. In: Green DP, ed. Operative hand surgery, 3rd ed. New

York: Churchill Livingstone, 1993:768.

23. Ames EL, Bissonnette M, Acland R, et al. Arterial anatomy of

the thumb. J Hand Surg [Br] 18:427–436, 1993.

24. Earley MJ. The arterial supply of the thumb, first web and

index finger and its surgical application. J Hand Surg [Br] 11:

163–174, 1986.

25. Coleman SS, Anson BJ. Arterial patterns in the hand based on

a study of 650 specimens. Surg Gynecol Obstet 113:409–424,

1961.

26. Tountas CP, Bergman RA. Anatomic variations of the upper

extremity. New York: Churchill Livingstone, 1993.

27. Lindsey JT, Watamull D. Anatomic study of the ulnar nerve

and related vascular anatomy at Guyon’s canal: a practical classification system. J Hand Surg [Am] 21:626–633, 1996.

28. Konig PSA, Hage JJ, Bloem JJAM, et al. Variations of the ulnar

nerve and ulnar artery in Guyon’s canal: a cadaveric study. J

Hand Surg [Am] 19:617–722, 1994.

29. Farabeuf LH. Precis de manuel operatoire. Paris: Masson, 1909:

38–41.

30. Landsmeer JMF. Atlas of anatomy of the hand. Edinburgh:

Churchill Livingstone, 1976:264–276.

31. Zeiss J, Jakab E, Khimji T, et al. The ulnar tunnel at the wrist

(Guyon’s canal): normal MR anatomy and variants. AJR Am J

Roentgenol 158:1081–1085, 1992.

32. Jaschtschinski SN. Morphologie und Topographie des Arcus

Volaris Sublimis und Profundus. Anat Hefte 7:163–188, 1897.

33. Tandler J. Zur Anatomie der Arterien der Hand. Anat Hefte 7:

263–282, 1897.

34. Adachi B. Das Arteriensystem der Japener, Band 1. Kyoto:

Maruzen, 1928.

35. Gray DJ. Some variations appearing in the dissecting room.

Stanford Med Bull 3:120–127, 1945.

36. Gellman H, Botte MJ, Shankwiler J, et al. Arterial patterns of

638 Regional Anatomy

the deep and superficial palmar arches. Clin Orthop 383:

41–46, 2001.

37. Strauch B, de Moura W. Arterial system of the fingers. J Hand

Surg [Am] 15:148–154, 1990.

38. Nakamura J, Kinoshita Y, Hama H, et al. Successful replantation of four fingers with a single common digital artery anastomosis. J Microsurg 2:35–37, 1980.

39. Tonkin MA, Ames EL, Wolff TW, et al. Transmetacarpal amputations and replantation: the importance of the normal vascular

anatomy. J Hand Surg [Br] 13:204–209, 1988.

40. Parks BJ, Arbelaez J, Horner RL. Medical and surgical importance of the arterial blood supply of the thumb. J Hand Surg

[Am] 3:383–385, 1978.

41. Weathersby HT. The artery of the index finger. Anat Rec

122:57–64, 1955.

42. Martin CH, Seiler JG III, Lesesne JS. The cutaneous innervation of the palm: an anatomic study of the ulnar and median

nerves. J Hand Surg [Am] 21:634–638, 1996.

43. Watchmaker GP, Weber D, Mackinnon SE. Avoidance of transection of the palmar cutaneous branch of the median nerve in

carpal tunnel release. J Hand Surg [Am] 21:644–650, 1996.

44. Jolley BJ, Stern PJ, Starling T. Patterns of median nerve sensory

innervation to the thumb and index finger: an anatomic study.

J Hand Surg [Am] 22:228–231, 1997.

45. Bas H, Kleinert JM. Anatomic variations in sensory innervation

of the hand and digits. J Hand Surg [Am] 24:1171–1184,

1999.

46. Chen Y-G, McClinton MA, DaSilva MF, et al. Innervation of

the metacarpophalangeal and interphalangeal joints: a microanatomic and histologic study of the nerve endings. J Hand

Surg [Am] 25:128–133, 2000.

47. Wallace WA, Coupland RE. Variations in the nerves of the

thumb and index finger. J Bone Joint Surg Br 57:491–494,

1975.

48. Mumford J, Morecraft R, Blair WF. Anatomy of the thenar

branch of the median nerve. J Hand Surg [Am] 12:361–365,

1987.

49. Poisel S. Ursprung und Verlauf des R. Muscularis des Nervus

Digitalis Palmaris Communis I (N. Medianus). Chir Praxis 18:

471–474, 1974.

50. Lanz U. Anatomical variations of the median nerve in the carpal

tunnel. J Hand Surg [Am] 2:44–53, 1977.

51. Tountas CP, Bihrle DM, MacDonald CJ, et al. Variations of the

median nerve in the carpal canal. J Hand Surg [Am] 12:

708–712, 1987.

52. Entin MA. Carpal tunnel syndrome and its variants. Surg Clin

North Am 48:1097, 1968.

53. Mannerfelt L, Hybinette C-H. Important anomaly of the

thenar motor branch of the median nerve. Bull Hosp Joint Dis

33:15–21, 1972.

54. Linburg RM, Albright JA. An anomalous branch of the median

nerve. J Bone Joint Surg Am 54:1779–1781, 1972.

55. Eiken O, Carstam N, Eddeland A. Anomalous distal branching

of the median nerve. Scand J Plast Reconstr Surg 5:149–152,

1971.

56. Kessler I. Unusual distribution of the median nerve at the wrist.

Clin Orthop 67:124–126, 1971.

57. Kuschner SH, Gelberman RH, Jennings C. Ulnar nerve compression at the wrist. J Hand Surg [Am] 13:577–580, 1988.

58. Gross NS, Gelberman RH. The anatomy of the distal ulnar

tunnel. Clin Orthop 196:238–247, 1984.

59. Bonnel F Vila RM. Anatomical study of the ulnar nerve in the

hand. J Hand Surg [Br] 10:165–168, 1985.

60. Manske PR, McCarroll HR Jr. Abductor digiti minimi opponensplasty in congenital radial dysplasia. J Hand Surg[Am] 3:

552–559, 1978.

61. Meals RA, Shaner M. Variations in digital sensory patterns: a

study of the ulnar nerve-median nerve palmar communicating

branch. J Hand Surg[Am] 8:411–414, 1983.

62. Ferrari GP, Gilbert A. The superficial anastomosis on the palm

of the hand between the ulnar and median nerves. J Hand Surg

[Br] 16:511–514, 1991.

63. Salisbury CR. The interosseous muscles of the hand. J Anat 71:

395–403, 1937.

64. Eyler DL, Markee JE. The anatomy and function of the intrinsic musculature of the fingers. J Bone Joint Surg Am 36:1–9,

1954.

65. Hepburn D. The comparative anatomy of the muscles and

nerves of the superior and inferior extremities of the anthropoid

apes. J Anat 26:149–185, 1892.

66. Linscheid RL, An K-N, Gross RM. Quantitative analysis of the

intrinsic muscles of the hand. Clin Anat 4:265–284, 1991.

67. Smith RJ. Intrinsic muscles of the fingers: function, dysfunction, and surgical reconstruction. Instr Course Lect 24:

200–220, 1975.

68. Haines RW. The extensor apparatus of the finger. J Anat

85:251–259, 1951.

69. Long C II, Conrad PW, Hall EA, et al. Intrinsic-extrinsic muscle control of the hand in power grip and precision handling: an

electromyographic study. J Bone Joint Surg Am 52:853–867,

1970.

70. Backhouse KM, Catton WT. An experimental study of the

functions of the lumbrical muscles in the human hand. J Anat

88:133–141, 1954.

71. Gans C. Fiber architecture and muscle function. Exerc Sport Sci

Rev 10:160–207, 1982.

72. Jacobson MD, Raab R, Fazeli BM, et al. Architectural design of

the human intrinsic hand muscles. J Hand Surg [Am] 17:

804–809, 1992.

73. Landsmeer JMF. The anatomy of the dorsal aponeurosis of the

human finger and its functional significance. Anat Rec 104:

31–44, 1949.

74. Harris C Jr, Rutledge GL Jr. The functional anatomy of the

extensor mechanism of the finger. J Bone Joint Surg Am 54:

713–726, 1972.

75. Schultz RJ, Furlong J, Storace A. Detailed anatomy of the

extensor mechanism at the proximal aspect of the finger. J Hand

Surg[Am] 6:493–498, 1981.

76. Weitbrecht J. Syndesmologia sive historia ligamentorum corporis

humani, quam secundum observationes anatomicas concinnavit, et

figuris and objecta recentia adumbratis illustravit. Petropoli: Ex

Typographia Academiae Scientiarum, Anno MDCCXLII.

77. Milford LW. Retaining ligaments of the hand. Philadelphia: WB

Saunders, 1968.

78. Stack HG. Muscle function in the fingers. J Bone Joint Surg Br

44:899, 1962.

79. Zancolli E. Structural and dynamic basis of hand surgery.

Philadelphia: JB Lippincott, 1968.

80. Finochietto R. Retraccion de Volkmann de los musculos intrinsecos de los manos. Bol Trab Soci Cir Buenos Aires 4:31–50,

1920.

81. Parkes AR. Traumatic ischemia of peripheral nerves, with some

observations on Volkmann’s ischemic contracture. Br J Surg

32:403, 1945.

82. Kilgore ES Jr, Graham WP, et al. The extensor plus finger. Hand

7:159–165, 1975.

83. Parkes A. The “lumbrical plus” finger. Hand 2:164–167, 1970.

84. Gosset J. Dupuytren’s disease and the anatomy of the palmodigital aponeuroses. In: Hueston JT, Tubiana R, eds. Dupuytren’s

disease, 2nd ed. Edinburgh: Churchill Livingstone, 1985:

13–26.

85. McGrouther DA. Dupuytren’s contracture. In: Green DP, ed.

10.1 Palmar Hand 639

Operative hand surgery, 4th ed. New York: Churchill Livingstone, 1999:563–591.

86. Grapow M. Die anatomie und physiologische Bedeutung der

Palmaraponeurose. Arch Anat Entwicklungsgeschichte 143–

158, 1887.

87. Defrenne HA. Les structures aponevnotiques au niveau de la

premiere commissure. Ann Chir 31:1017–1019, 1977.

88. Bojsen-Moller F, Schmidt L. The palmar aponeurosis and the

central spaces of the hand. J Anat 117:55–68, 1974.

89. Legueu F, Juvara E. Des aponeuroses de la paume de la main.

Bull Soc Anat Paris 383–400, 1892.

90. Manske PR, Lesker PA. Palmar aponeurosis pulley. J Hand

Surg[Am] 8:259–263, 1983.

91. Doyle JR. Anatomy and function of the palmar aponeurosis

pulley. J Hand Surg[Am] 15:78–82, 1990.

92. Grayson J. The cutaneous ligaments of the digits. J Anat 75:

164, 1941.

93. Cleland J. On the cutaneous ligaments of the phalanges. J Anat

Physiol 12:526, 1878.

94. Kline SC, Moore JR. The transverse carpal ligament—an

important component of the digital flexor pulley system. J Bone

Joint Surg Am 74:1478–1485, 1992.

95. Doyle JR, Blythe W. The finger flexor tendon sheath and pulleys: anatomy and reconstruction. In: AAOS symposium on tendon surgery in the hand. St. Louis: CV Mosby, 1975.

96. Resnick D. Roentgenographic anatomy of the tendon sheaths

of the hand and wrist: tenography. AJR Am J Roentgenol 124:

44–51, 1975.

97. Scheldrup EW. Tendon sheath patterns in the hand, an anatomical study based on 367 hand dissections. Surg Gynecol Obstet

93:16–22, 1951.

98. Bunnell SB. Surgery of the hand. Philadelphia: JB Lippincott,

1944.

99. Cohen MJ, Kaplan L. Histology and ultrastructure of the

human flexor tendon sheath. J Hand Surg [Am] 12:25–29,

1987.

100. Whitaker CR. The arrangement of the synovial membrane in

the palmar digital sheaths. J Anat 41:155–157, 1907.

101. Doyle JR. Anatomy of the finger flexor sheath and pulley system. J Hand Surg [Am] 13:473–484, 1988.

102. Azar C, Fleegler EJ, Culver JE. Dynamic anatomy of the flexor

pulley system of the finger and thumb. Presented at the 39th

annual meeting of the American Society for Surgery of the

Hand, Atlanta, 1984.

103. Lundborg G, Myrhage R, Rydevik B. The vascularization of

human flexor tendons within the digital synovial sheath region:

structural and functional aspects. J Hand Surg[Am] 2:417–427,

1977.

104. Knott C, Schmidt HM. The fibrous reinforcing arrangements

of the digital peritenons in the human hand. Gegenbaurs

Morph Jahrb 132:1–28, 1986.

105. Weber ER. Nutritional pathways for the flexor tendons in the

digital theca. In: Hunter JM, Schneider LH, Mackin EJ, eds.

Tendon surgery in the hand. St. Louis: Mosby, 1987.

106. Amis AA, Jones MM. The interior of the flexor tendon sheath

of the finger: the functional significance of its structure. J Bone

Joint Surg Br 70:583–587, 1988.

107. Doyle JR, Blythe W. Anatomy of the flexor tendon sheath and

pulleys of the thumb. J Hand Surg[Am] 2:149–151, 1977.

108. Kanavel AB. Infections of the hand, 6th ed. London: Bailliere,

Tindall and Cox, 1934.

109. Parona F. Dell’oncotomia negli accessi profundi diffusi dell’avambrachio. Annali Universali di Medicina e Chirurgia,

Milano, 1876.

110. Armenta E, Lehrman A. The vincula to the flexor tendons of

the hand. J Hand Surg [Am] 5:127–134, 1980.

111. Ochiai N, Matsui T, Miyaji N, et al. Vascular anatomy of flexor

tendons: I. vincular system and blood supply of the profundus

tendon in the digital sheath. J Hand Surg [Am] 4:321–330,

1979.

112. Armenta E, Fisher J. Anatomy of flexor pollicis longus vinculum system. J Hand Surg [Am] 9:210–212, 1984.

113. Flindall E, McGrouther DA. Accessory roles of the vinculum

breve of the flexor digitorum profundus and check-rein ligaments at the distal interphalangeal joint. J Hand Surg [Br] 16:

305–310, 1991.

114. Bruner JM. The zig-zag volar-digital incision for flexor tendon

surgery. Plast Reconstr Surg 40:571–574, 1967.

115. Boyes JH, Stark HH. Flexor tendon grafts in the fingers and

thumb: a study of factors influencing results in 1000 cases. J

Bone Joint Surg Am 53:1332–1342, 1971.

116. Eaton RG, Malerich MM. Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten years experience. J

Hand Surg [Am] 5:260–268, 1980.

117. Luck JV. Dupuytren’s contracture: a new concept of the pathogenesis correlated with surgical management. J Bone Joint Surg

Am 41:635–664, 1959.

118. McFarlane RM. Dupuytren’s contracture. In: Green DP, ed.

Operative hand surgery, 3rd ed. New York: Churchill Livingstone, 1993.

119. Skoog T. The transverse elements of the palmar aponeurosis in

Dupuytren’s contracture. Scand J Plast Surg 1:51–63, 1967.

120. Strickland JW, Bassett RL. The isolated digital cord in

Dupuytren’s contracture: anatomy and clinical significance. J

Hand Surg [Am] 10:118–124, 1985.

121. Wolfe SW. Tenosynovitis. In: Green DP, ed. Operative hand

surgery, 4th ed. New York: Churchill Livingstone, 1999.

122. Sampson SP, Baldamente MA, Hurst LC, et al. Pathobiology of

the human A1 pulley in trigger finger. J Hand Surg [Am] 16:

714–721, 1991.

123. Pope DF, Wolfe SW. Safety and efficacy of percutaneous trigger

finger release. J Hand Surg [Am] 20:280–283, 1995.

124. Cardon LJ, Ezaki M, Carter PR. Trigger finger in children. J

Hand Surg [Am] 24:1156–1161, 1999.

125. Weilby A. Trigger finger: incidence in children and adults and

the possibility of a predisposition in certain age groups. Acta

Orthop Scand 41:419–427, 1970.

126. Tordai P, Engkvist O. Trigger fingers in children. J Hand Surg

[Am] 24:1162–1165, 1999.

127. Bowers WH, Kuzma GR, Bynum DK. Closed traumatic rupture

of finger flexor pulleys. J Hand Surg [Am] 19:782–787, 1994.

128. Bollen SR. Injury to the A2 pulley in rock climbers. J Hand

Surg [Br] 15:268–270, 1990.

129. Lin GT, Amadio PC, An K-N, et al. Biomechanical analysis of

finger flexor pulley reconstruction. J Hand Surg [Br] 14:

278–282, 1989.

130. Le Viet D, Rousselin B, Roulot E, et al. Diagnosis of digital pulley rupture by computed tomography. J Hand Surg [Am] 21:

245–248, 1996.

131. Tropet Y, Menez D, Balmar P, et al. Closed traumatic rupture of

the ring finger flexor tendon pulley. J Hand Surg [Am] 15:

745–747, 1990.

132. Glickel SZ, Malerich M, Pearce SM, et al. Ligament replacement for chronic instability of the ulnar collateral ligament of

the metacarpophalangeal joint of the thumb. J Hand Surg [Am]

18:930–941, 1993.

133. Bowers WH, Hurst LC. Gamekeeper’s thumb: evaluation by

arthrography and stress roentgenography. J Bone Joint Surg Am

59:519–524, 1977.

134. Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: a clinical

and anatomical study. J Bone Joint Surg Br 44:869–879, 1962.

640 Regional Anatomy

135. Stener B. Skeletal injuries associated with rupture of the ulnar

collateral ligament of the metacarpophalangeal joint of the

thumb: a clinical and anatomical study. Acta Chir Scand 125:

583–586, 1963.

136. Stener B, Stener I. Shearing fractures associated with rupture of

the ulnar collateral ligament of the metacarpophalangeal joint

of the thumb. Injury 1:12–16, 1969.

137. Kaplan SJ. The Stener lesion revisited: a case report. J Hand

Surg [Am] 23:833–836, 1998.

138. Hintermann B, Holzach PJ, Schultz M, et al. Skier’s thumb: the

significance of bony injuries. Am J Sports Med 21:800–804,

1993.

139. Kuz JE, Husband JB, Tokar N, et al. Outcome of avulsion fractures of the ulnar base of the proximal phalanx of the thumb

treated nonsurgically. J Hand Surg [Am] 24:275–282, 1999.

140. Abrahamsson S-O, Sollerman C, Lundborg G, et al. Diagnosis of

displaced ulnar collateral ligament of the metacarpophalangeal

joint of the thumb. J Hand Surg [Am] 15:457–460, 1990.

141. Dinowitz M, Trumble T, Hanel D, et al. Failure of cast immobilization for thumb ulnar collateral ligament avulsion fractures.

J Hand Surg [Am] 22:1057–1063, 1997.

142. Bean CHG, Tencer AF, Trumble TE. The effect of thumb

metacarpophalangeal ulnar collateral ligament attachment site

on joint range of motion: an in vitro study. J Hand Surg [Am]

24:283–287, 1999.

143. Basuk RS, Melone CP. Radial instability of the thumb metacarpophalangeal joint: a clinical and anatomic analysis. Orthop

Trans 10:203, 1986.

144. Camp RA, Weatherwax RJ, Miller EB. Chronic post traumatic

radial instability of the thumb metacarpophalangeal joint. J

Hand Surg[Am] 5:221–225, 1980.

145. Durham JW, Khuri S, Kim MH. Acute and late radial collateral

ligament injuries of the thumb metacarpophalangeal joint. J

Hand Surg [Am] 18:232–237, 1993.

146. Krause JO, Manske PR, Mirly HL, et al. Isolated injuries to the

dorsoradial capsule of the thumb metacarpophalangeal joint. J

Hand Surg [Am] 21:428–433, 1996.

147. van Wetter T. Biometrie et physiologie du ponce. Acta Orthop

Belg 37:403–443, 1971.

148. Doyle JR, Atkinson RE. Rupture of the radial collateral ligament of the metacarpophalangeal joint of the index finger: a

report of three cases. J Hand Surg [Br] 14:248–250, 1989.

149. Hughes LA, Freiberg A. Irreducible MP joint dislocation due to

entrapment of FPL. J Hand Surg [Br] 18:708–709, 1993.

150. Adler GA, Light TR. Simultaneous complex dislocation of the

metacarpophalangeal joints of the long and index fingers: a case

report. J Bone Joint Surg 63:1007–1009, 1981.

151. Lane CS. Detecting occult fractures of the metacarpal head: the

Brewerton view. J Hand Surg[Am] 2:131–133, 1977.

152. McLaughlin HL. Complex “locked” dislocation of the metacarpophalangeal joints. J Trauma 5:683–688, 1965.

153. Becton JL, Christian JD, Goodwin HN, et al. A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 57:698–700, 1975.

154. Grant IR. Irreducible rotational anterior dislocation of the

proximal interphalangeal joint: a spin drier injury. J Hand Surg

[Br] 18:648–651, 1993.

155. Green DP, Butler TE Jr. Fractures and dislocations in the hand.

In: Rockwood CA Jr, Green DP, Bucholz RW, et al., eds. Rockwood and Green’s fractures in adults, 4th ed. Philadelphia: Lippincott–Raven, 1996.

156. Garroway RY, Hurst LC, Leppard J, et al. Complex dislocation of

the proximal interphalangeal joint. Orthop Rev 8:21–28, 1984.

157. Eaton RG. Joint injuries of the hand. Springfield, IL: Charles C

Thomas, 1971.

158. Spinner M, Choi BY. Anterior dislocation of the proximal interphalangeal joint, a cause of rupture of the central slip of the extensor mechanism. J Bone Joint Surg Am 52:1329–1336, 1970.

159. Peimer CA, Sullivan DJ, Wild WR. Palmar dislocation of the

proximal interphalangeal joint. J Hand Surg [Am] 9:39–48,

1984.

160. Diao E, Eaton RG. Total collateral ligament excision for contractures of the proximal interphalangeal joint. J Hand Surg

[Am] 18:395–402, 1993.

161. Bunnell SB. Discussion of Curtis reference #162. J Bone Joint

Surg Am 36:1232, 1954.

162. Curtis RM. Capsulectomy of the interphalangeal joints of the

fingers. J Bone Joint Surg Am 36:1219–1231, 1954.

163. Harness D, Sekeles E. The double anastomotic innervation of

the thenar muscles. J Anat 109:461–466, 1971.

164. Cannieu A. Recherche sur l’innervation de l’eminence thenar

par le cubital. J Med Bord 377–379, 1896.

165. Cannieu A. Note sur une anastomose entre le branche profunde

du cubital et le median. Bull Soc Anat Physiol Horm Pathol

Bord 17:339–342, 1897.

166. Riche P. Le nerf cubital et les muscles de l’eminence thenar. Bull

Mem Soc Anat Paris 251–252, 1897.

167. Littler JW. The physiology and dynamic function of the hand.

Surg Clin North Am 40:259, 1960.

168. McFarlane RM. Observations on the functional anatomy of the

intrinsic muscles of the thumb. J Bone Joint Surg Am 44:1073,

1962.

169. Rogers MR, Bergfield TG, Aulicino PL. A neural loop of the

deep motor branch of the ulnar nerve: an anatomic study. J

Hand Surg [Am] 16:269–271, 1991.

170. Tonkin MA, Lister GD. The palmaris brevis profundus: an

anomalous muscle associated with ulnar nerve compression at

the wrist. J Hand Surg [Am] 10:862–864, 1985.

10.1 Palmar Hand 641

CHAPTER

HAND

JAMES R. DOYLE

1 0

PART

DORSAL HAND

DESCRIPTIVE ANATOMY

Contents

Bone: Metacarpals and phalanges of the five rays.

Nerves: Terminal branches of the median, radial, and

ulnar nerves.

Tendons: The extensor tendons of the five rays.

Fascia: The extensor retinaculum.

Blood Vessels: Dorsal veins.

Appendages: Nail matrix and nails.

Landmarks

Important superficial landmarks on the dorsum of the wrist

and hand include Lister’s tubercle, the anatomic snuff-box,

the lunate fossa, the styloid process at the base of the middle finger metacarpal, the radial styloid process, and the distal head of the ulna (Fig. 10.85).

Lister’s Tubercle

This bony prominence on the dorsal aspect of the distal

radius is situated approximately 0.5 cm proximal to the dorsal margin of the articular surface of the radius. It is in line

with the cleft between the index and middle finger

metacarpals. The extensor pollicis longus (EPL), located in a

groove just ulnar to Lister’s tubercle, turns radialward around

Lister’s tubercle on its way to the dorsal aspect of the thumb.

The extensor carpi radialis brevis (ECRB) is just radial to Lister’s tubercle in a similar groove on the dorsum of the radius.

Anatomic Snuff-Box

The anatomic snuff-box, a narrow triangle with its apex

located distally, is bordered dorsoulnarly by the EPL, radi2

ally by the abductor pollicis longus and extensor pollicis

brevis (EPB) tendons, and proximally by the distal margin

of the extensor retinaculum. In its depths it contains the

dorsal branch of the radial artery; in its dorsoulnar corner,

the tendon of the extensor carpi radialis longus (ECRL);

and superficially, one or more branches of the superficial

branch of the radial nerve (1,2).

Lunate Fossa

The lunate fossa is a palpable central depression located on

the dorsum of the wrist in line with the longitudinal axis of

the third metacarpal, just ulnar and distal to Lister’s tubercle, and beginning immediately distal to the dorsal margin

of the radius. It is, on average, approximately the size of the

pulp of an examiner’s thumb and marks the location of the

carpal lunate.

Styloid Process of the Middle Finger

Metacarpal

The styloid process of the middle finger metacarpal, located

on the dorsal and radial base of this metacarpal, points to

the articular interface between the capitate and the trapezoid and is just proximal to the point of insertion of the

ECRB tendon.

Radial Styloid

The distal projection of the radial side of the radius forms a

visible and easily examined landmark that is palpable both

palmar and dorsal to the abductor pollicis longus and EPB

tendons that course across its apex.

Distal Head of the Ulna

The distal aspect of the ulna is slightly expanded and contains

a head and a comparatively small styloid process. The head is

most visible and palpable with the forearm in pronation. The

styloid process is a short, rounded, dorsoulnar projection from

the ulnar head that is most readily palpable in supination and

is approximately 1 cm proximal to the plane of the radial styloid. The apex of the triangular fibrocartilage attaches to the

palmar-radial base of the ulnar styloid. The ECU runs in a

fibroosseous groove along the dorsal aspect of the head (1).

ANATOMIC RELATIONSHIPS

Skin Coverage

The skin on the dorsum of the hand and fingers is comparatively thin and pliable; this may be demonstrated by

pinching the skin between the thumb and index finger and

tenting it up. This mobility is due to its comparative thinness and lack of fibrous tissue attachments to the underlying fascia. This comparison is made to the palmar skin,

which is thick, firmly attached to the underlying fascia,

with folds along creases or flexion lines. The dorsal skin

glides and stretches with movement. The dorsal skin’s

accommodation to the requirements of flexion are most

noticeable over the wrist, metacarpophalangeal (MCP), and

proximal interphalangeal (PIP) joints, where the skin folds,

accordion-like, in extension and flattens out in flexion.

These accordion-like folds are the dorsal counterpart of the

palmar skin creases (1).

Clinical Significance

These characteristics of the dorsal skin make it less likely to

form an undesirable scar, even when incisions are placed at

right angles to the extension folds.

10.2 Dorsal Hand 643

FIGURE 10.85. A,B: External landmarks on the dorsum of the hand.

A B

Venous Drainage of the Digits

Fingers

Dorsal Digital Veins

Lucas, in an injection study of 36 fingers, noted that

although there is greater variability in the venous than in the

arterial system, there is a fairly consistent dorsal venous pattern (3) (Fig. 10.86). The most consistent vessel found is a

small vein in the dorsal midline of the distal phalanx that

arborized over the surface of the nail matrix and was named

the dorsal terminal vein. Lateral terminations that parallel the

nail margins also are fairly constant. These veins are large

enough to reapproximate by microvascular techniques (3–5).

Proximally, a pair of dorsal veins (one ulnar and one radial)

are joined by transversely oriented connections that form a

“dorsal ladder” that ends at the digital cleft. Moss et al. studied the venous anatomy of the hand and fingers in nine fresh

cadaver hands and observed that the dorsal venous system of

each digit consists of a series of arches, one over each phalanx,

with the most proximal arch being consistently present in all

digits studied (6). These authors called the arch of veins running around the lateral nail wall and distal pulp the distal

venous arch. The distal arch is connected to a middle venous

arch by means of midline longitudinal vessels over the middle phalanx, and the middle arch is the most rudimentary of

644 Regional Anatomy

the three arches. The middle arch is connected by multiple

longitudinal vessels, the largest of which are on either side of

the PIP joint, to the proximal venous arch over the proximal

phalanx. The proximal arch terminates in veins in the dorsal

web spaces on either side of the MCP joint, which in turn

join the veins on the dorsum of the hand. These veins form

a network that is connected proximally to the cephalic and

basilic veins (Fig. 10.87). This network is divided into two

systems: The first consists of interdigital communications

between the proximal arches of each digit that lie in the dorsal web spaces between the MCP joints; the second system

(the more dominant) consists of three distinct venous arcades

over the metacarpals. There is one metacarpal arcade for each

of the venous arches of the thumb and small finger. The proximal venous arches of the remaining digits communicate with

a large central metacarpal arcade that extends from the radial

side of the index metacarpal to the ulnar side of the ring finger metacarpal (6).

Smith et al., in a comprehensive study that focused on

the veins distal to the PIP joint, sited and counted all of the

veins encountered at the PIP and distal interphalangeal

(DIP) joints and eponychial regions of 67 fingers (7). The

study was performed to note the regions at these various

locations that would be most likely to have suitable vessels

for anastomosis in cases of replantation.

FIGURE 10.86. Dorsal and palmar veins

of the digits: composite patterns of the

dorsal and palmar digital veins. The

small triangles indicate the site of valves.

The most consistent vessel found is a

small vein in the dorsal midline of the

distal phalanx that arborizes over the

surface of the nail matrix, called the dorsal terminal vein. Lateral terminations

that parallel the nail margins also are

fairly constant. Proximally, a pair of dorsal veins (one ulnar and one radial) are

joined by transversely oriented connections that form a “dorsal ladder” that

ends at the digital cleft. A similar “palmar ladder” is present in the flexor

aspect of the finger, although the vessels

are somewhat smaller. (Redrawn after

Lucas GL. The pattern of venous

drainage of the digits. J Hand Surg [Am]

9:448–450, 1984, with permission.)

Proximal Interphalangeal Joint Level

Numerous large vessels were noted dorsally, with almost

total avascularity on the radial and ulnar aspects. For veins

that measured >0.8 mm, the dorsal/palmar vein ratio was

138:98. Thus, when performing a microvascular vein repair

(replantation) in this region, the surgeon should look first

for veins on the dorsum and next on the palmar side, but

not waste any time looking for veins on the radial or ulnar

aspects of the finger.

Distal Interphalangeal Joint Level

This amputation site is characterized by the dorsal terminal vein, and in 68% in Smith and colleagues’ study it

was a single vessel that measured >0.5 mm 96% of the

time.

Thus, the surgeon always should look first in the area of

the middle one-third of the dorsal aspect of the digit; the

second-best choice is in the region of the commissural vein.

These are lateral veins connecting the palmar to the dorsal

system and were present in 49 of 67 fingers (73%); one vein

measured >0.8 mm. Medium-size veins (<0.7 to >0.5 mm)

were present an average of 1.1 veins per finger. These

medium-size veins were more common on the palmar side,

134 versus 74 on the dorsal side.

10.2 Dorsal Hand 645

Eponychial Level

This is a very distal level and if replantation is pursued, the

surgeon’s efforts to find a suitable distal vein may be optimized

by first finding the lateral commissural vein in the proximal

stump and then trying to identify its counterpart in the amputated part—topographically, a relatively small area. If not successful, the surgeon should next look for the lateral ramifications of the dorsal terminal vein, also a small topographic area.

Last, the entire area of the palmar pulp should be searched.

Palmar Digital Veins

Lucas noted that a similar “palmar ladder” is present in the

flexor aspect of the finger, although the vessels are somewhat

smaller (3). These vessels do not travel with the digital arteries as venae comitantes, but have a more random course in

and out of the fascial sheath formed by Grayson’s and Cleland’s ligaments. The longitudinal components of the palmar

ladder parallel the neurovascular bundle but are more superficial. These two ladders are joined by oblique anastomotic

veins that are especially prominent in the proximal segment

of the finger. Both systems drain the bones of the fingers and

the vincular system. Both dorsal and palmar web veins are

present and interconnected. Moss et al. noted that palmar

venous drainage was composed of a superficial and a deep

FIGURE 10.87. Metacarpal venous arcades. The veins on the

dorsum of the hand form a network that is connected proximally to the cephalic and basilic veins.

system (6). The deep system, according to Moss et al., corresponded to the venae comitantes of the proper digital arteries that join with the superficial palmar veins to form the

venae comitantes of the common digital arteries in the hand.

The superficial system consists of two networks overlying the

neurovascular bundles. Transverse and oblique communicating veins join the two superficial palmar networks. These two

superficial palmar networks are surrounded by a sheath of

fine connective tissue that encases the veins in a cushion of

fat. This perivenous arrangement serves to support the superficial veins; they collapse when this sheath is removed. These

superficial palmar digital veins unite in the web space to form

a common vein (the intercapitular vein), which then passes

proximally and dorsally to join the dorsal metacarpal arcades.

A transverse natatory vein (also called the palmar venous arch)

courses along the margin of the natatory ligament to join

with each web space vein.

Oblique Communicating Veins

Moss et al. identified communicating veins from the superficial palmar venous system that pass obliquely, proximally,

and dorsally (the “dorsal oblique communicating veins”) to

join the dorsal digital venous system and that are larger and

more numerous in the mid-portion of the proximal phalanx

(6). Transverse sections revealed 10 to 12 veins at all levels

of section. Palmar veins become smaller and less regular in

the proximal phalanx compared with the middle phalanx;

large, oblique communicating veins are present at the middle third of the proximal phalanx.

Venous Valves

Moss et al. noted that valves are present in all the digital veins

studied, including veins with cross-sectional diameters of

<0.1 mm (6) (see Fig. 10.86). These valves occur as far distally as the distal part of the distal phalanx, and their location

is identified by noting a clam-shaped node in the vein. These

valves are bicuspid with the valve leaflets arranged parallel to

the skin. This parallel orientation ensures their competence

with extrinsic pressure on the skin. The valves direct blood

flow from distal to proximal, palmar to dorsal, and radial to

ulnar. Valves are present on the dorsal surface of the fingers at

specific branch points and at the mouths of the tributaries

entering the three transverse arches. No valves are present in

the arches except for one at the ulnar end of the proximal

venous arch, which is oriented to direct flow ulnarly into the

proximal venous arch of the adjacent digit. More valves are

present on the palmar aspect and are arranged in series along

the superficial and deep systems; the highest density is in the

distal pulp.

Direction and Sequence of Venous Flow

A valve is present at either end of the transverse and oblique

veins that connect the radial and ulnar superficial palmar systems; they are arranged to direct flow into either one or the

other system, but prohibit flow between them. Valves are pre646 Regional Anatomy

sent in all veins that pass from palmar to dorsal and are

arranged so that flow is from palmar to dorsal. Sequential

angiographic studies by Moss et al. revealed flow from the

dorsal distal arch to the middle and proximal arches. Flow

from the proximal arch is into the next arch in an ulnar direction and into the metacarpal arcade. The thumb metacarpal

arcade empties into the cephalic vein, but the central

metacarpal arcade flows into the cephalic and basilic veins,

with a preference for the ulnar-sided basilic system (6).

Thumb

Matloub et al., in a study of 20 injected thumbs, identified

a dominant longitudinal network, palmar veins in the pulp,

oblique veins at the interphalangeal joint on the radial side,

and a web space (ulnar) vein (8). A layered pattern with a

fine superficial network over a deeper system was found.

Cross-sections were made at the distal phalanx, the proximal

phalanx, and the MCP joint, and the location of the veins

noted in four quadrants. The most characteristic findings

were sizable palmar veins in the pulp, an oblique radial communicating vein arising at the level of the interphalangeal

joint, a web space (ulnar) vein, the relative dominance of the

dorsal system, and the presence of suitable veins (>0.5 mm)

near the nail matrix. The authors’ cross-sections showed that

the dorsal system is dominant proximally and the palmar

system is important distally. Veins were found to be present

at all palmar levels; the radial side of the interphalangeal

joint and proximal phalanx and the ulnar side of the web

space can be anticipated to be a reliable source of veins in

replantation surgery (8) (Fig. 10.88).

FIGURE 10.88. Venous anatomy of the thumb. Characteristic

pattern of the dorsal and palmar veins of the thumb [after Matloub et al. (8)].

Dorsal Veins

The dorsal system of veins begins at the base of the thumbnail and coalesces into four to eight large vessels (usually <1

mm in diameter) at the level of the interphalangeal joint. As

these vessels approach the MCP joint, they decrease in

number but increase in size. At the level of the MCP joint,

there usually were two to three vessels with a diameter of 1

to 1.5 mm (8).

Palmar Veins

The palmar system is not as well developed as the dorsal

and begins as one or usually two 0.5-mm veins deep in the

pulp of the terminal phalanx. These vessels are beneath a

superficial plexus of much smaller vessels connected by

numerous small transverse anastomoses. Proximal to the

interphalangeal joint, these veins begin a dorsal course up

the radial and ulnar sides of the thumb to join the dorsal

veins (8).

Clinical Significance of the Anatomy of the

Venous Drainage of the Digits

In addition to the specific recommendations made by

Smith et al. (7) and noted previously, several observations

may be made in reference to the structure and arrangement of this system based on the study of Moss et al. (6):

(a) The superficial and deep palmar veins along with the

neurovascular bundles are so placed that they escape compression during grasp or pinch; (b) when pressure is

applied to the palm, the blood may easily pass to the dorsum by means of the oblique communicating veins, and

reflux is prevented by the valves; (c) the oblique communicating veins are concentrated at the mid-portion of the

proximal phalanx, which is the zone of least compression

when making a fist; (d) the shape of the soft tissues in the

middle and proximal phalanges changes from ovoid to a

more rectangular configuration during flexion, and the

vascular channels lie in the corners of this rectangle and

thus avoid compression; (e) in replantation, failure to recognize the presence of a valve at an anastomosis site may

impede flow; and (f) in replantation, the practice of

lengthening veins by selectively dividing tributaries distally and placing them proximally should be done with

care to avoid incorporating a reversed valve that could

impede venous return (6).

Pumping Action and Venous Outflow of

the Hand

Simons et al. identified three independent venous outflow systems in the hand: superficial palmar, deep palmar,

and dorsal veins (9). Pumping action is achieved by making a fist, which results in palm compression, isometric

intrinsic contraction, and dorsal compression and tightening of the skin. Each of the three systems may increase

10.2 Dorsal Hand 647

venous blood velocity in both the cephalic and ulnar

veins. Digit abduction increased the volume of blood

being pumped (9).

Perforating veins were found to be distal (in the web

spaces near the MCP joints), proximal (near the base of the

metacarpals), and carpal (between the bases of the

metacarpals and a line drawn through the radial tubercle

and the midpoint of the ulnar head). The proximal perforators at the radial and ulnar aspect of the hand were large

and constant. Ultrasound studies revealed that blood could

be pumped effectively by each of the systems independently, although the systems act in synergy. The deep pump

is more significant in the cold hand because of constriction

of the dorsal veins (9). These authors, citing the study of

Lavizzari and Ottolini, noted that the perforators probably

had valves that prevented reflux of blood from the dorsal to

the deep system (10).

Clinical Significance of Pumping Action

1. Effective venous filling is essential during venipuncture

to engorge the veins. Although normally accomplished

by fist-clinching, dorsal venous filling may be augmented by repetitive finger abduction (activation of the

intrinsic muscle pump by isometric contraction).

2. Such maneuvers also may be of value when injecting

thrombogenic or sclerosing agents, where a high venous

flow is advantageous.

3. Edema after surgery or trauma is a common cause of

hand stiffness, and when ordinary means of control,

including elevation and active motion, are not possible,

the deep muscle pump may be activated by isometric

contraction of the intrinsic muscles (9).

Extensor Retinaculum

Gross Anatomy

The wrist, thumb, and finger extensors gain entrance to

the hand beneath the extensor retinaculum through a

series of six tunnels, five fibroosseous and one fibrous

[the fifth dorsal compartment, which contains the extensor digiti minimi (EDM)] (11). The extensor retinaculum

is a wide fibrous band that prevents bowstringing of the

tendons across the wrist joint (Fig. 10.89). Its average

width is 4.9 cm (range, 2.9 to 8.4 cm) as measured over

the fourth compartment (11). At this level, the extensor

tendons are covered with a synovial sheath. The extensor

retinaculum consists of two layers: the supratendinous

and the infratendinous. The infratendinous layer is limited to an area deep to the ulnar three compartments. The

six dorsal compartments are separated by septa that arise

from the supratendinous retinaculum and insert onto the

radius (12).

Histology

Three distinct layers have been identified: (a) an inner gliding layer with hyaluronic acid–secreting cells with isolated

areas of chondroid metaplasia; (b) a thick middle layer with

collagen bundles oriented in various directions, fibroblasts,

and elastin fibers; and (c) the outer layer of loose connective

tissue with vascular channels. This is the same histologic

arrangement seen in anatomic pulleys throughout the body

that provides a smooth gliding surface with mechanical

strength (13).

Clinical Significance

The basic function of the extensor retinaculum is to avoid

bowstringing of the extensor tendons, which explains the

648 Regional Anatomy

presence of chondroid metaplasia, an adaptation in

response to friction and the dorsal forces produced by

extensor tendon action. The extensor retinaculum has been

found to be a useful tissue for flexor tendon pulley reconstruction because of its histologic similarity to the native

pulley in the fingers (14).

Extensor Tendon Anatomy

The extensor mechanism arises from multiple muscle bellies in the forearm. The EPL, EPB, extensor indicis proprius

(EIP), and EDM have a comparatively independent origin

and action (15). The proprius tendons at the MCP joint

level usually (see discussion under Anatomic Variations,

later) are to the ulnar side of the communis tendons. The

FIGURE 10.89. The wrist extensor retinaculum and the most common arrangement of the extensor tendons and juncturae. The wrist, thumb, and finger extensors gain entrance to the hand

beneath the extensor retinaculum through a series of six tunnels, and at this level are covered

with a synovial sheath.

small finger proprius tendon (EDM) over the metacarpal

and wrist level usually is represented by two distinct tendinous structures. Kaplan and others, however, noted that the

variations in the disposition and the number of tendons are

numerous (15,16). Kaplan believed that the extensor digitorum communis (EDC) usually had four distinct tendons

and was characterized by limited independent action, in

contrast to the proprius tendons (15). My own operative

experience and cadaver dissections parallel the cadaver

observations of Schenck and von Schroeder and Botte, that

the EDC tendon to the small finger is present less than

50% of the time (17,18). When it is absent, it almost

always is replaced by a junctura tendinum from the ring finger to the extensor aponeurosis of the small finger (17,18).

Most Common Arrangement of the

Finger Extensor Tendons

Based on a study of 43 cadaver hands, the most common distribution pattern of finger extensors is: (a) a single EIP that

inserted ulnar to the EDC of the index finger; (b) a single

EDC to the index finger; (c) a single EDC to the long finger;

(d) a double EDC to the ring; (e) an absent EDC to the small

finger; and (f) a double EDM with a double insertion into

the small finger (18) (see Fig. 10.89). Variations in this

arrangement are given in the section on Anatomic Variations.

The concurrently accepted zones of injury are given in

Figure 10.90.

Tables 10.12 and 10.13 give the average thickness of the

extensor mechanism in the fingers and thumb.

Proximal Interphalangeal Joint Dorsal

Plate

A unique arrangement is present at the dorsal aspect of the

PIP joint, where the central slip of the extensor tendon

invests a fibrocartilage plate before its attachment to the

dorsal base of the middle phalanx. The average thickness of

the central slip at this level is 0.5 mm, but because of the

presence of this fibrocartilage plate, the thickness is doubled

10.2 Dorsal Hand 649

FIGURE 10.90. The zones of extensor injury.

TABLE 10.12. AVERAGE THICKNESS OF EXTENSOR

MECHANISM IN FINGERS

Finger Average Thickness of Average Thickness of

Zone Extensor (mm) Lateral Bands (mm)

I 0.65 —

II 0.55 0.6

III 1.00a —

IV 0.60 1.0

V 1.40 —

VI 1.70 —

aThis measurement was taken at the dorsal plate over the PIP joint.

The central slip just proximal to the dorsal plate measured 0.5 mm.

TABLE 10.13. AVERAGE THICKNESS OF EXTENSOR

MECHANISM IN THUMB

Thumb Average Thickness Average Thickness of

Zone of Extensor (mm) Lateral Bands (mm)

I 0.60 —

II 0.80 0.3

III 1.20 EPL —

0.85 EPB

IV 1.30 EPL —

0.95 EPB

EPL, extensor pollicis longus; EPB, extensor pollicis brevis.

over the PIP joint. Slattery named this structure the dorsal

plate and described its structure in detail, noting that its

function might relate to stability of the extensor tendon,

stability of the PIP joint, an increase of the moment arm of

the extensor tendon at the PIP joint, and prevention of

attrition of the central slip at the PIP joint (19). The similarity of the dorsal plate and the patella is striking (19). In

my experience, the dorsal plate adds relative thickness and

substance to the extensor mechanism and aids in the placement of sutures for lacerations in this area.

Juncturae Tendinum

The extensor tendons are interconnected on the dorsum of

the hand by intertendinous fascia and juncturae tendinum.

The intertendinous fascia is present between all tendons of

the fourth compartment and attaches to the paratenon of

the extensors. In contrast, the juncturae tendinum are narrow connective tissue bands that extend between the EDC

and EDM (but not the EIP) and attach to the tendons (see

Fig. 10.89). In a comprehensive study of the juncturae

tendinum in 40 cadaver hands, von Schroeder et al.

described three distinct morphologic types of junctura

tendinum (20):

Type I: This consists of filamentous regions in the intertendinous fascia that contain small bands of connective tis650 Regional Anatomy

sue. Type I juncturae tendinum are seen most often in the

second and third interspaces, and are the only type seen in

the second interspace. Their shape is square, rhomboidal, or

triangular, and they usually are obliquely oriented. Type I

bands attached to the EDC tendon but did not connect to

normal or aberrant EIP tendons (Fig. 10.91).

Type II: This is a much thicker, primarily rhomboidal in

shape, and well defined intertendinous connecting band

most commonly seen in the third and fourth interspaces.

Type II juncturae tendinum are more distally located than

type I. Eight of the nine hands with type II juncturae that

occurred in the fourth interspace also had an EDC to the

small finger (19 of 40 hands had an EDC to the small finger). In all of these eight hands, the juncturae passed from

the small finger EDC to the ring finger EDC (Fig. 10.92).

Type III: This type consists of tendon slips from the

extensor tendons and is the longest, narrowest, and thickest

of the three types. They occur in the third and fourth (most

common) interspace and are classified into “y” or “r” subtypes based on their shape. The y-subtype is defined as a

tendon that splits into two equal halves that insert into the

two tendons of adjacent digits. One slip is defined as the yjunctura and the other as the continuation of the base tendon (Fig. 10.93). The r-subtype is a more oblique junctura

tendinum arising from a base tendon (Fig. 10.94). In all of

the hands with type III juncturae in the third space, the

interconnections ran from the EDC of the ring finger to the

FIGURE 10.91. Type I junctura tendinum [after von Schroeder et

al. (20)]. Type I is a filamentous intertendinous fascia that contains small bands of connective tissue and is seen most often in

the second and third interspaces. Its shape is square, rhomboidal,

or triangular. They do not connect to normal or aberrant extensor indicis proprius tendons.

FIGURE 10.92. Type II junctura tendinum: This is a much thicker,

primarily rhomboidal, well defined intertendinous connecting

band seen most commonly in the third and fourth interspaces.

Type II juncturae tendinum are more distally located than type I.

tendon of the long finger. Twelve were of the r-subtype and

one was a y-subtype. In those hands with an EDC to the

small finger (19 of 40), 11 had a type III interconnection,

and in 8 of those 11 cases the junctura tendinum ran from

the EDC of the small finger to the ring finger. In 3 of the

11, cases the junctura tendinum ran from the ring finger

EDC to the small finger EDC. In the 11 hands with a type

III junctura tendinum and an EDC tendon to the small finger, 7 of the juncturae tendinum were of the y-subtype and

4 were r-subtype. In the absence of an EDC to the small

finger (21 of 40 cases), 19 of the 21 had an r-subtype junctura tendinum from the ring finger EDC to the small finger that blended with the radial slip of the EDM or dorsal

hood.

Clinical Significance

Identification of the EIP when it is used as a tendon transfer is aided by the fact that it does not have a junctura

tendinum. Laceration of the middle finger communis tendon over the metacarpal just proximal to the junctura may

result in only partial extension loss of the middle finger

10.2 Dorsal Hand 651

(21). In a study of the role of long finger extensors and the

juncturae tendinum, von Schroeder and Botte noted that

traction on the EIP tendon could produce extension of

the middle finger in spite of the normal absence of the

juncturae tendinum (22). They noted that this extension

force was transmitted through the intertendinous fascia,

mesotenon, and web space fibers, including the transverse

metacarpal ligament and natatory ligaments, which may

partially insert into the extensor hood. The juncturae

tendinum were shown to have considerable interaction

between adjacent fingers, and also may decrease the stress

on the web. Sectioning the web virtually abolished any

movement between adjacent fingers, in contrast to transection of the long extensors, which had no effect on the

interaction between the fingers. This finding is of significance when evaluating an injured hand because a lacerated

tendon may be overlooked if finger extension is partially

maintained through juncturae, intertendinous fascia, or

the web structures between the adjacent fingers (22).

Although Gonzalez et al. did not identify a junctura tendinum between the index and middle finger EDC, but

rather a thin, wispy structure, their findings and conclusions are at variance with other authors who have written

about the extensor mechanism and who have accepted it

as a junctura tendinum (20,22–24). Although this junctura is thin, its presence and functional significance have

been demonstrated by Kitano and associates (24), who

noted that excision of this structure when it was present in

FIGURE 10.93. Type III junctura tendinum: This type consists of

tendon slips from the extensor tendons and is the longest, narrowest, and thickest of the three types. They occur in the third

and fourth (most common) interspace and are classified into “y”

or “r” subtypes based on their shape. The “y” type shown here

is defined as a tendon that splits into two equal halves that

insert into the two tendons of adjacent digits. One slip is defined

as the y-junctura and the other as the continuation of the base

tendon.

FIGURE 10.94. Type III junctura tendinum (r-subtype). The rsubtype is a more oblique junctura tendinum arising from a base

tendon.

its thicker and more substantial form was required to

maintain independent index finger extension after EIP

transfer.

Sagittal Bands

The extensor tendon at the MCP joint level is held in place

over the dorsum of the joint by the conjoined tendons of

the intrinsic muscles and the transverse lamina or sagittal

bands, which together tether and keep the extensor tendons

centralized over the joint (15) (see Fig. 10.89). The sagittal

bands arise from the palmar plate and the intermetacarpal

ligaments at the neck of the metacarpals (15,25). The fibers

of the sagittal bands are perpendicular to the EDC in neutral position, angulated 25 degrees at 45 degrees of MCP

flexion, and angulated 55 degrees at full MCP flexion. Pressure readings deep to the sagittal bands revealed that the

greatest pressure occurred during complete MCP joint flexion and the least at 45 degrees of flexion. When MCP joint

radial or ulnar deviation was evaluated, the average measurement was greatest in neutral MCP joint position and

least in 45 degrees of flexion (26). Serial sectioning of the

ulnar sagittal band failed to produce extensor tendon instability, whereas partial proximal but not distal sectioning of

the radial sagittal band produced tendon subluxation.

Complete sectioning of the radial sagittal band produced

tendon dislocation. Wrist flexion increased tendon instability after radial sagittal band sectioning (26).

Clinical Significance

The sagittal band maintains the EDC tendon centralized

over the MCP joint during flexion and extension. During

hyperextension of the finger at the MCP joint, the sagittal

band prevents bowstringing of the EDC (27). The degree of

extensor tendon instability is determined by the extent of

radial sagittal band disruption, and proximal rather than

distal sagittal band compromise contributes to extensor

instability (26).

Functional Dynamics of the Extensor

Mechanism

Extension of the finger is a complex act and is considered to

be more intricate than finger flexion. This mechanism is

composed of two separate and neurologically independent

systems—namely, the radial nerve–innervated extrinsic

extensors and the intrinsic systems supplied by the ulnar

and median nerves (25).

At the MCP joint level, the intrinsic muscles and tendons are palmar to the joint axis of rotation. At the PIP

joint, however, they are dorsal to the joint axis. The extensor mechanism at the PIP joint is best described as a trifurcation of the extensor tendon into the central slip,

652 Regional Anatomy

which attaches to the dorsal base of the middle phalanx

and the two lateral bands (28). The lateral bands pass on

either side of the PIP joint and continue distally to insert

at the dorsal base of the distal phalanx. The extensor

mechanism is maintained in place over the PIP joint by

the transverse retinacular ligaments. The extensor tendon

achieves simultaneous extension of the two finger joints

by a mechanism in which the central slip extends the middle phalanx and the lateral bands bypass the PIP joint to

extend the distal phalanx. The fibers overlying the PIP

joint are differentially loaded as the finger moves. In the

flexed position, the most central fibers are tensed, whereas

in extension the lateral fibers are tensed (29,30). The most

important feature of this mechanism is that the three elements are in balance (28,31). Specifically, the lengths of

the central slip and two lateral bands must be such that

extension of the PIP and DIP joints takes place together,

so that when the middle phalanx is brought up into alignment with the proximal phalanx, the distal phalanx

reaches alignment at the same time (28). This mechanism

depends on the relative lengths of the central slip and two

lateral bands. This precise and consistent length relationship is what is so difficult to restore when the mechanism

has been damaged (28,31,32).

Patterns of Imbalance

Disruption of the extensor mechanism at the DIP joint

results in mallet finger; disruption of the central slip at the

PIP joint results in the characteristic boutonniere deformity, and a swan neck deformity may be a secondary result

of the mallet finger (28) (Fig. 10.95).

Proprius Tendons

Traditional knowledge has suggested that independent

extension of the index and small fingers was due solely to

the proprius tendons to these digits. Loss of independent

extension, especially of the index finger, was said to be

highly probable if the index proprius was injured and not

repaired, or was transferred. This concept as it applies to the

index finger was not confirmed by Moore et al., who noted

independent index extension in 20 of 27 patients after

extensor indicis transfer (33). They suggested that the reasons for the presence of independent action after extensor

indicis transfer were (a) the EDC in all cases had four distinct muscle bellies with separate and distinct innervation

from the posterior interosseous nerve, and (b) the junctura

tendinum between the index and long fingers was filamentous and poorly developed compared with the more ulnar

digits, which had well developed and thick juncturae that

limited independent extension. They also noted that

despite complete release of the juncturae tendinum, full

independent excursion of the long or ring finger MCP joint

was not obtained, which suggested that extracapsular con-

straints limited independent extension of the long and ring

fingers when adjacent fingers were held in flexion. Index

finger extension and strength after EIP transfer was studied

by Noorda and associates in 34 patients (34). Twenty-four

of the 34 patients had extension lag in the index finger, and

all of the patients had reduced extension strength in the

donor index finger either measured dependently (with concurrent middle finger extension) or independently (without

middle finger extension). The authors concluded that the

reduction in strength of extension probably was not the

cause of the extensor lag, but that the extensor lag most

likely was due to disruption of the normal hood function or

excursion. Despite these findings, 30 of the 34 patients

described no limitations in their daily activities. The

authors noted that to prevent extension lag, the surgeon

10.2 Dorsal Hand 653

should avoid surgical trauma to the hood mechanism by

sectioning the EIP proximal to the hood (34). The issue of

independent index finger extension after indicis proprius

transfer also was studied by Kitano and associates, who also

noted that the EDC to the index finger was well separated

from the other EDC muscle bellies and received a distinct

and separate innervation from the posterior interosseous

nerve (24). In 13 hands with EIP transfer, they noted independent extension of the index finger in all cases after excision of the junctura tendinum between the index and middle fingers. Based on this surgical experience and

companion cadaver studies, the authors concluded that

independent extension of the index was likely after transfer

of the EIP if the extensor hood was intact and the junctura

tendinum was excised.

FIGURE 10.95. Deformities related to disruption

and imbalance of the extensor mechanism. A: Mallet finger. B: Boutonniere deformity. C: Swan neck

deformity.

A

B

C

Nail Unit

Nomenclature

A standardized nomenclature and anatomic configuration

are given in Figure 10.96.

Macroscopic Anatomy

Nail Plate

The hard, often shiny, fingernail or thumbnail is called the

nail plate. The nail plate is homologous to the stratum

corneum of the epidermis and consists of compacted, anucleate, keratin-filled squames with dorsal, intermediate, and

palmar layers (1). It is slightly convex in the longitudinal

axis and more convex in the transverse axis. The lunula is a

white opacity immediately distal to the central aspect of the

proximal nail fold and is said to be due to comparatively

poor vascularization of the germinal matrix (5,35).

Nail Fold

Proximally, the nail plate extends under the semilunar nail

fold, which is lined with dorsal and palmar epidermis. The

stratum corneum layer of the dorsal layer of epidermis

654 Regional Anatomy

extends distally over the nail plate to form the cuticle or

eponychium. The lunula is approximately at the junction

between the germinal and sterile matrix (5).

Nail Bed

The nail plate rests on the nail bed (matrix), which is

defined as all the soft tissue immediately beneath the nail

plate and that participates in nail generation and migration

(5). The nail bed is a specialized form of epithelium with a

proximal zone of germinal matrix and a distal zone of sterile matrix. The distal margin of the lunula is approximately

at the junction between the germinal and sterile matrix (5).

A sagittal section of the distal phalanx reveals a wedgeshaped collection of cells with the proximal portion of the

nail plate embedded in their substance. Thus, dorsal and

palmar components of the matrix are noted. The palmar

matrix cells are continuous distally with the nail bed. The

nail bed is grooved and ridged longitudinally, which

matches a similar pattern on the undersurface of the nail

plate and may be a factor in stabilizing the nail for functional demands. Beneath the epithelium of the nail bed is a

dermis layer that is anchored to the underlying periosteum

of the distal phalanx by fibrous tissue. Keratinized cells are

FIGURE 10.96. Anatomy and nomenclature of the nail unit. 1, Arcade of nail wall; 2, arcade of

germinal matrix; 3, arcade of sterile matrix.

extruded from the dorsal and palmar germinal matrix cells

to produce the nail plate, with the major production coming from the palmar cells. The area of epidermis under the

distal edge of the nail plate is called the hyponychium. The

stratum corneum layer is undulant and constantly being

shed. The hyponychium provides an important barrier

against entry of bacteria.

Clinical Significance. A smooth nail bed is essential for

regrowth of a normal nail plate. In nail bed injuries, primary healing cannot occur if the bed is not accurately

reapproximated. If the scar is in the dorsal matrix, a dull

streak may appear in the nail plate; if the scar is in the

intermediate portion of the germinal matrix, a split or

absent nail may occur; if the scar is in the palmar nail or

sterile matrix, a split or nonadherence of the nail beyond

the scar may occur (5,36).

Blood Supply and Drainage

The arterial blood supply to the nail bed comes from two

dorsal branches from the common palmar digital artery; the

proximal vessel is a dorsal branch to the nail fold, and the

second courses along the lateral nail plate margin and sends

branches to the nail bed (Fig. 10.97). These vessels anastomose dorsally with their counterparts to form arcades.

10.2 Dorsal Hand 655

Branches from these vessels and the arcades form sinuses

surrounded by muscle fibers and help to regulate the blood

pressure and blood supply to the extremities (5,35,36).

These networks have been identified as papillary, reticular,

and subdermal and correspond to the general architecture

of the vessels of the skin. The dermis of the nail bed is well

vascularized and includes large arteriovenous shunts (glomera) (1). There is reduced vascular density in the region of

the germinal matrix, in contrast to an increased vascular

density in the sterile matrix. The comparatively less vascularized germinal matrix demonstrates a well developed subdermal network located near a zone of loose connective tissue that is poorly vascularized near the proximal part of the

distal phalanx. This zone may be a sliding apparatus

between the nail and the distal attachment of the extensor

tendon (35). Venous drainage is by a coalescence of veins in

the skin proximal to the nail fold that course proximally in

a random fashion over the dorsum of the digit (4). These

veins are of sufficient size for microvascular anastomosis (4).

Nerve Supply

The nail unit is innervated by branches from the paired

digital nerves. The most common pattern (70%) was represented by a branch that passed beneath the nail plate

and into the nail bed at approximately the level of the

FIGURE 10.97. Arterial supply of the distal phalanx. The arterial blood supply to the nail bed

comes from two dorsal branches from the common palmar digital artery; the proximal vessel is a

dorsal branch to the nail fold; the second courses along the lateral nail plate margin and sends

branches to the nail bed. These vessels anastomose dorsally with their counterparts to form

arcades. Branches from these vessels and the arcades form sinuses surrounded by muscle fibers

and help to regulate the blood pressure and blood supply to the extremities. 1, Network of nail

wall; 2, arcade of germinal matrix; 3, arcade of sterile matrix.

lunula and a second branch that passed distally to end at

the hyponychial area (4). There are numerous sensory

nerve endings, including Merkel discs and Meissner corpuscles (1).

Nail Plate Growth

Growth rate is determined by the turnover rate of the germinal matrix, which varies with age, digit (the long fingernail grows faster than the small fingernail), environmental

temperature, season, time of day, and nutritional status.

Rate of growth in the long finger is approximately 0.1

mm/day. As the matrix cells enlarge, they grow distally

because of the confinement of the nail fold. As the matrix

cells enlarge, they are flattened by the pressure of newly

forming cells beneath them (5). This pressure and confinement result in a nail plate that is flat and grows distally. The

dorsal layer of the germinal matrix produces nail cells that

are relatively shiny, and if these cells are removed or damaged, the nail surface will appear dull (5).

Function of the Nail Unit

The nail unit assists in digital pad sensibility by providing

support and counterpressure for the digital pad. Both grasp

and pinch are aided by the nail unit, which provides dorsal

and peripheral anchoring and stability to the palmar pad.

The functional spectrum may span from the simple act

of scratching an itch to the manipulation and picking up of

small objects.

Relationship of the Germinal Matrix to the

Extensor Tendon Insertion

Based on microscopic dissection, the distance from the terminal aspect of insertion of the extensor tendon and the

proximal edge of the germinal matrix was found to be on

average 1.2 mm (range, 0.9 to 1.8 mm) (37).

Clinical Significance

When the extensor tendon insertion is visualized during

operative procedures on the dorsum of the distal phalanx,

care should be taken to avoid damage to the germinal

matrix. Conversely, when the germinal matrix is being

removed for total ablation of a nail, dissection does not

need to be carried proximal to the distalmost fibers of the

extensor tendon (37).

SURGICAL EXPOSURES

Metacarpophalangeal Joint/Proximal

Phalanx

Indications

This surgical exposure has been found to be useful for

arthrotomy of the MCP joint for intraarticular fracture, foreign or loose body, fractures of the proximal phalanx, dislo656 Regional Anatomy

cations of the MCP joint, dislocations of the extensor tendon, dorsal capsulotomy or capsulectomy, and arthroplasty

of the MCP joint.

Landmarks

Landmarks include the apex of the MCP joint and the

underlying extensor mechanism, which are most noticeable

when the MCP is flexed.

Incision

A straight or slightly curved longitudinal incision is suitable

for single or multiple exposures. An alternative choice is a

transverse incision centered over the MCP joint, and is

designed to be used when multiple MCP joints are to be

exposed either for release or arthroplasty (Fig. 10.98).

Technique

In both the longitudinal and transverse skin incisions, the

veins in the interosseous gutters between the metacarpal

heads must be protected and preserved. Sensory branches

of the radial or ulnar nerves are identified and preserved

based on the location of the incision. In cases of dorsal

capsulotomy or capsulectomy, the sagittal bands may be

elevated and retracted distally to expose the underlying

dorsal capsule and the proximal origins of the collateral

ligaments. In cases requiring more comprehensive exposure, the extensor hood, beginning at or proximal to the

level of the sagittal bands, is split longitudinally in the

substance of the extensor tendon (38). This tendon-splitting incision is extended proximally and distally to meet

the needs of the particular condition being treated. The

benefit of this tendon/hood-splitting incision is to maintain balance between the incised parts so that with postoperative motion, the extensor mechanism tracks normally and does not subluxate (38). In the index finger, this

incision is between the proprius and communis tendons.

In the small finger, it is centered over the apex of the joint

and between the two slips of the EDM or the EDC, based

on their presence or absence. Care is taken to avoid

detachment of the central slip of the extensor tendon at

the dorsal base of the middle phalanx, and the tendon

splitting should stop proximal to the PIP joint.

Proximal Interphalangeal Joint

(Fig. 10.99)

Indications

This incision may be used for exposure of the central slip of

the extensor tendon for lacerations, management of acute

and chronic boutonniere lesions, and bilateral capsulotomy

and capsulectomy of the joint.

Incision

The incision may be slightly curved or longitudinal, centered over the PIP joint.

Technique

The incision is carried down to the paratenon over the

extensor mechanism. The dorsal veins are cauterized or tied

and the flaps are developed and reflected to each side. Both

the dorsal as well as the radial and ulnar sides of the extensor mechanism and the PIP joint may be exposed.

Distal Interphalangeal Joint (Dorsal)

Indications

This approach may be used for exposure of the DIP joint

for fracture, laceration of the extensor mechanism, or nail

matrix removal.

10.2 Dorsal Hand 657

Incision

Dorsal approaches to the DIP joint region may be longitudinal, a proximally or laterally based chevron, or a bayonettype incision (see Fig. 10.99). Precautions: Remember that

the distance from the terminal aspect of insertion of the

extensor tendon and the proximal edge of the germinal

matrix is on average 1.2 mm (range, 0.9 to 1.8 mm), and

when the germinal matrix is being removed for total ablation of a nail, dissection does not need to be carried proximal to the distalmost fibers of the extensor tendon (37).

CLINICAL CORRELATIONS

Mallet Finger

Definition and Physical Findings

Loss of continuity of the conjoined lateral bands at the distal joint of the finger results in a characteristic flexion deforFIGURE 10.98. Surgical approach to the

metacarpophalangeal (MCP) joint and

proximal phalanx. A: A straight or

slightly curved longitudinal incision is

suitable for single or multiple exposures.

An alternative choice is a transverse incision centered over the MCP joint

designed to be used when multiple MCP

joints are to be exposed either for release

or arthroplasty. B: The extensor hood is

incised longitudinally in the substance of

the extensor tendon.

A

B

mity of the distal joint called mallet, baseball, or drop finger.

The distal joint assumes varying degrees of flexion and the

patient cannot actively extend the distal segment, although

full passive extension usually is present. Hyperextension of

the middle joint also may be observed and is due to unopposed central slip tension at the PIP joint and joint laxity

(39). In recent injuries, there is swelling and tenderness over

the dorsum of the distal joint.

Anatomy of the Mallet Finger

The lateral bands from each side of the digit merge and

conjoin to form one tendon just distal to the dorsal tubercle on the proximal portion of the middle phalanx. This

tendon continues distally to form a wide unit for insertion

into the dorsal base of the distal phalanx. The tendon

attaches to the dorsal part of the capsule and inserts into a

ridge distal to the articular cartilage from one collateral ligament to the other (40). Warren and colleagues, in a study

of the microvascular anatomy of distal digital extensor tendon, noted an area of deficient blood supply in this area and

suggested that this zone of avascularity might have implications in the cause and treatment of mallet finger (41). The

pathologic anatomy is depicted in Figure 10.95A.

Boutonniere Lesion

Definition and Physical Findings

Disruption of the central slip of the extensor tendon at the

PIP joint level along with volar migration of the lateral

658 Regional Anatomy

bands results in the so-called boutonniere deformity, with

subsequent loss of extension at the middle joint and compensatory hyperextension at the distal joint. This lesion

may be secondary to closed blunt trauma with acute forceful flexion of the PIP joint, producing avulsion of the central slip from its insertion on the dorsal base of the middle

phalanx with or without fracture and laceration of the

extensor tendon at or near its insertion (42). The pathologic

anatomy is depicted in Figure 10.95B.

Early Diagnosis

In closed injuries, the characteristic boutonniere deformity

may not be present at the time of injury and usually develops over a 10- to 21-day period after injury. This condition

often is missed even in an open wound. A painful, tender,

and swollen PIP joint that has been recently injured should

arouse suspicion. Early diagnosis of this central slip injury

(before the classic deformity of PIP joint flexion and DIP

extension develops) is based on evaluation of the status of

the central slip attachment. Isolation of the effect of the

central slip of the PIP joint is achieved by maintaining the

PIP joint in flexion to rule out the contribution of the lateral bands.

The Elson Test

In a study that used various published clinical tests to diagnose an early boutonniere, only the Elson test was said to be

reliable (43,44). This test relies on abnormal tone between

FIGURE 10.99. Surgical approaches to the proximal

(PIP) and distal interphalangeal (DIP) joints. Typical skin

incisions are shown that may be used to expose the PIP

and DIP joints.

the PIP and DIP joints. Normally, with the PIP joint

blocked in flexion, there is limited active extension of the

DIP joint. Harris and Rutledge demonstrated that the lateral bands are held distally by the central slip, and because

of this check-rein effect the extensor mechanism is unable

to extend the DIP joint (28). However, with disruption of

the central slip and loss of the check-rein effect, extension

of the DIP can occur by tightening the dorsal apparatus. In

a boutonniere lesion, attempted active extension of the finger with the PIP joint held in flexion increases the rigidity

of the DIP joint.

Technique. The finger to be examined is flexed comfortably

to a right angle at the PIP joint over the edge of a table and

firmly held in place by the examiner (Fig. 10.100).

The patient is then asked to extend the PIP joint against

resistance. Any pressure felt by the examiner over the middle phalanx can only be exerted by an intact central slip.

Further proof is that the DIP joint remains flail during the

effort because the competent central slip prevents the lateral

bands from acting distally. In the presence of a complete

rupture of the central slip, any extension effort perceived by

the examiner is accompanied by rigidity at the DIP joint

with a tendency to extension. This is produced by the

extensor action of the lateral bands. This test, however, does

10.2 Dorsal Hand 659

not demonstrate the presence of a partial rupture of the

central slip, and it may be impeded by pain or lack of

patient cooperation. Consideration may be given to nerve

block for pain relief as indicated.

Clinical Significance

Early diagnosis of boutonniere gives the best chance of a

satisfactory outcome. Once again, only the Elson test was

said to be reliable in an early diagnosis of boutonniere (see

Elson Test above).

“Pseudoboutonniere” Deformity

McCue et al., in 1970, used the term pseudoboutonniere

to describe a condition of PIP joint flexion contracture

with associated restricted flexion of the DIP joint (45).

Based on his study of PIP joint anatomy and hyperextension injuries of the PIP joint, Bowers noted that the confluence of origin of the palmar plate, the first cruciform

pulley, and the oblique retinacular ligament could theoretically provide an anatomic basis for such a contracture

(46,47). Inflammation secondary to a hyperextension

injury could result in contracture of the check-rein ligaments, the oblique retinacular ligaments, and possibly the

first cruciform pulley to produce PIP joint flexion conFIGURE 10.100. The Elson test for detection

of the boutonniere lesion. A, B: The finger to

be examined is flexed comfortably to a right

angle at the proximal interphalangeal (PIP)

joint over the edge of a table and firmly held

in place by the examiner, and the patient is

asked to extend the PIP joint. Any pressure

felt by the examiner through extension of the

middle phalanx can be exerted only by an

intact central slip; further proof is that the distal interphalangeal (DIP) joint remains flail

during the effort because the competent central slip prevents the lateral bands from acting

distally. C, D: If the central slip is disrupted,

any extension effort perceived by the examiner is accompanied by rigidity at the DIP joint

with a tendency to extension. This test does

not demonstrate the presence of a partial

rupture of the central slip, and it may be

impeded by pain or lack of patient cooperation.

A–B

C–D

tracture as well as loss of flexion of the DIP joint owing

to contracture of the oblique retinacular ligament. The

pseudoboutoniere deformity must be distinguished from

the true boutonniere because the pathologic process and

treatment are different. Proper diagnosis is aided by a

detailed history of the injury as well as the initial physical findings.

Anatomic Pathomechanics of the Boutonniere

Deformity

The boutonniere deformity illustrates the problem of

imbalance in the finger, which is a chain of joints with

multiple tendon attachments. This chain collapses into

an abnormal posture or deformity when there is an

imbalance of the critical forces maintaining equilibrium

(42,48). Zancolli has divided this sequence into three

stages (49). At first, there is flexion of the PIP joint due

to loss of the central slip and the unopposed force of the

flexor digitorum superficialis. Later, with stretching of

the expansion (transverse retinacular ligament and triangular ligament) between the central and lateral slips, the

lateral bands migrate volarward to a position volar to the

axis of joint rotation. Finally, in this position of the lateral bands, the pull of the intrinsic muscles is directed

exclusively to the distal joint, which progressively hyperextends. The MCP joint also is hyperextended by action

of the long extensor tendon. Treatment of the early acute

boutonniere deformity is arbitrarily divided into closed

or avulsion injuries, and open injuries with laceration of

the extensor tendons at or near the PIP joint.

Methods of Treatment of Chronic

Boutonniere Deformity

Correction of this deformity depends on restoration of the

normal tendon balance and the precise length relationship

of the central slip and lateral bands. The various techniques

used to manage both acute and chronic boutonniere deformity are published elsewhere, and the reader is referred to

these resources (50,51).

Swan Neck Deformity

Definition

Swan neck deformity is characterized by hyperextension of

the PIP joint and flexion of the DIP joint. In its primary or

acute form, it may occur because of rupture of the attachments of the palmar plate, either proximally or distally. Its

secondary or progressive forms may be due to a chronic

mallet finger or conditions such as rheumatoid arthritis or

spasticity that result in imbalance of the forces working on

the PIP joint and extensor mechanism.

660 Regional Anatomy

Pathologic Anatomy

Any condition that results in an imbalance in the forces acting on the PIP joint, either from dynamic destabilizing

forces or loss of static restraints, may alter the force vectors

as applied to that joint. In swan neck deformity, the lateral

bands are translocated dorsally at the PIP joint. This results

in decreased tension in the extensor mechanism at the DIP

joint because of the fixed attachment of the central extensor

tendon at the PIP joint. In mallet finger deformity, the relative lengthening of the distal aspect of the extensor allows

dorsal migration of the lateral bands, and the deformity is

complemented by the powerful flexor digitorum profundus, which becomes an unopposed deforming force at the

DIP joint. Treatment of this condition is based on restoration of the critical balance between the extrinsic and intrinsic tendons involved and reestablishing the static integrity

of the PIP and DIP joints (see Fig. 10.95C).

Closed Sagittal Band Injuries

Definition and Physical Findings

Spontaneous rupture of the radial sagittal band with subsequent ulnarward subluxation or dislocation of the extensor

tendon in the nonrheumatoid patient may occur after

forceful flexion or extension of the finger (26,52–54). The

lesion is secondary to a tear of the sagittal band and oblique

fibers of the hood, usually on the radial side, although rupture of the ulnar sagittal band and radial dislocation has

been reported (54,55). Ulnar subluxation or dislocation of

the extensor tendon, sometimes accompanied by painful

snapping of the extensor tendon when making a fist, is the

usual finding, and in some, but not all cases may be associated with incomplete finger extension and ulnar deviation

of the involved digit (54,56).

Pathologic Anatomy

The middle finger most commonly is involved. This may be

due to an inherent anatomic weakness because the extensor

tendon of the long finger is situated on top of the transverse

fibers and has a comparatively loose attachment at this level

(54). Ishizuki, in a series of 16 cases all involving the middle finger, classified 5 as traumatic and 11 as spontaneous

according to the provoking cause (53). Those classified as

spontaneous had no history of trauma and occurred during

a common daily activity such as flicking the finger or crumpling paper. Traumatic dislocations were caused by a direct

blow or forced flexion of the MCP joint as a result of a contusion or fall. Ishizuki identified a superficial and deep layer

of the sagittal band and noted disruption only of the superficial layer in spontaneous cases and of both layers in traumatic cases (53). The end result is ulnar displacement of the

affected tendon and loss of its normal moment arm, and

thus weak and diminished extension of the involved finger.

Treatment is directed at restoring the normal anatomic relationships by splinting in early cases or surgical repair in

chronic cases.

Carpometacarpal Boss

Definition and Physical Findings

This condition is an often prominent mass at the dorsal

base of the second or third metacarpals and the adjacent

trapezoid and capitate. It may or may not be painful.

It is a bony, hard, nonmobile mass that may be tender.

Lateral radiographs demonstrate a bone mass with a vertical

cleft arising from the opposing and dorsal surfaces of the

metacarpal and carpal bone.

Treatment

These osteoarthritic or hypertrophic bone formations may

be removed if symptomatic, but should not be confused

with the more common dorsal carpal ganglion.

ANATOMIC VARIATIONS

Extensor Medii Proprius

The extensor medii proprius (EMP) is a muscle analogous to the EIP in that it has a similar origin but inserts

into the extensor aponeurosis of the middle finger (Fig.

10.101).

In a study of 58 hands, von Schroeder and Botte noted

the presence of the EMP in 6 hands for an incidence of

10.3% (57). The EMP usually is covered by the EDC and

usually is not seen until the EDC is retracted or removed.

The EMP was always distal and medial to the EIP on the

interosseous membrane and in all cases the two muscles had

a common origin. In four of six instances, the EMP was

represented by a single tendon (57). The insertion was palmar and ulnar to the EDC insertion on the middle finger.

The width of the tendon ranged from 10 to 30 mm.

Extensor Indicis et Medii Communis

The extensor indicis et medii communis (EIMC) is an

anomalous EIP that splits and inserts into both the index

and middle fingers (Fig. 10.102).

It was identified in the aforementioned study by von

Schroeder and Botte, who noted its presence in 2 of 58

hands for an incidence of 3.4% (57). The tendon split

into its index and middle finger components near the

myotendinous junction. In one specimen, the insertion

into the index was similar to the usual insertion of the

EIP on the palmar and ulnar aspect of the EDC. In the

other specimen, a double tendon was present, with one

tendon inserting into the usual EIP location and the sec10.2 Dorsal Hand 661

ond slip into the deep fascia near the MCP joint. In both

specimens, the insertion into the middle finger was not

into the extensor hood but into the joint capsule of the

middle finger in one case and into the deep fascia proximal to the MCP joint in the other case. The muscle belly

of the EIMC was similar to the EIP, and like the EIP had

no juncturae tendinum.

Clinical Significance of the EMP and the

EIMC

Awareness of the incidence of these two muscles and other

anomalous muscles may be helpful in extensor tendon identification as it relates to repair or reconstruction.

Extensor Digitorum Brevis Manus

The extensor digitorum brevis manus (EDBM) is an aberrant muscle on the dorsum of the hand that has an incidence of 3.3% based on dissections of 845 hands (58) (Fig.

10.103).

FIGURE 10.101. The extensor medii proprius (EMP). The EMP is

a muscle analogous to the extensor indicis proprius in that it has

a similar origin but inserts into the extensor aponeurosis of the

middle finger. The EMP usually is covered by the extensor digitorum communis (EDC) and usually is not seen until the EDC is

retracted or removed. (Redrawn after von Schroeder HP, Botte

MJ. The functional significance of the long extensors and juncturae tendinum in finger extension. J Hand Surg [Am] 18:

641–647, 1993, with permission.)

Clinically, the EDBM is a fusiform, usually soft mass,

on the dorsum of the hand between the index and middle

finger metacarpals. It becomes more noticeable and firm

when the wrist is slightly flexed and the fingers extended.

It may be associated with complaints of pain and may be

coincidentally associated with a dorsal wrist ganglion

(58,59). Ogura et al. identified 5 types (types I, IIa, b, and

c, and III) in their study of 17 EDBM muscles in 559

hands (58). The classification was based on the distal

insertion of the EDBM and the relationship of the muscle

to the EIP.

Type I:The EDBM inserted onto the dorsal aponeurosis of

the index finger, as would the EIP, but the EIP was absent.

Type II: Both the EIP and EDBM inserted on the index

finger.

Type IIa: A small or vestigial EIP arose from the ulna but

was confluent with the EDBM belly, which inserted on the

index.

Type IIb: The distal end of the EDBM belly joined the

EIP tendon.

Type IIc: The EIP inserted normally, but the thin EDBM

more ulnarly than the EIP, often with a membranous accessory slip that inserted on the middle finger.

Type III: The EIP inserted on the index finger, but the

EDBM inserted on the middle finger with or without an

accessory EIP to the middle finger.

662 Regional Anatomy

The EDBM originated from the proximal portion of

the posterior radiocarpal ligament near the lunate, and the

proximal short tendon of origin could be traced as far

proximal as the distal margin of the radius in 16 of 17

cases. The muscle had a single belly in all instances and

formed a prominence between the EDC tendons of the

index and middle fingers. In 12 of 17 cases it inserted on

the index finger, and in the remaining 5 it inserted on the

middle finger. The nerve supply was the posterior

interosseous nerve in all instances. Blood supply was from

a terminal posterior branch of the anterior interosseous

artery (58).

Clinical Significance

The EDBM must be distinguished from a dorsal wrist

ganglion. In some patients with EDBM, complaints of

discomfort and swelling may be noted. Physical examination reveals a longitudinally oriented, fusiform mass that

does not transilluminate and becomes firm with wrist flexion and finger extension (58,59). Although Ogura et al.

have suggested that in types I or IIa (absent or vestigial

EIP) division or partial release of the extensor retinaculum

may be considered rather than excision, I agree with

Dostal et al. that excision of the EDBM is appropriate

(58,59).

FIGURE 10.102. Extensor indicis et medii communis (EIMC).

The EIMC is an anomalous extensor indicis proprius that

divides and inserts into both the index and middle fingers. See

text for details. (Redrawn after von Schroeder HP, Botte MJ.

The functional significance of the long extensors and juncturae

tendinum in finger extension. J Hand Surg [Am] 18:641–647,

1993, with permission.)

Extensor Tendons of the Fingers—

Variations and Multiplicity

von Schroeder and Botte, in a study of 43 adult cadaver

hands, found that the most common pattern or arrangement of the extensor tendons was (a) a single EIP that

inserted into the MCP extensor hood ulnar to the EDC

tendon; (b) a single tendon from the EDC to the index and

middle fingers; (c) a double tendon from the EDC to the

ring finger; (d) an absent EDC to the small finger; and (e)

a double EDM tendon to the small finger with a double

insertion into the MCP hood (18). Frequent variations

included a double EIP tendon, a double or triple EDCmiddle finger, a single or triple EDC-ring finger, and a single or double EDC tendon to the small finger. Although

increased multiplicity of any tendon was not associated

with multiplicity of any other tendon, there was a thinner

type junctura tendinum between the index and middle fingers in such instances of multiplicity. An absent EDC tendon to the small finger was associated with an increased

incidence of a double EDC tendon to the ring finger and a

thick type III junctura tendinum between the EDC of the

ring finger and the EDM or dorsal aponeurosis of the small

finger (18). Gonzalez and associates, in a study of the extensor tendons to the index finger in 72 cadavers, found that

the classic description of the anatomy was present in 58 of

10.2 Dorsal Hand 663

72 hands (23). Sixty hands had a single EDC and EIP tendon, and the EIP tendon was ulnar to the EDC in 58 of 72

hands. In 10 hands, the EIP had a double slip, and in 2

hands the EDC to the index had a double slip. Two hands

had a single slip of the EIP, which was either volar or radial

to the EDC at the MCP joint. Overall, 14 hands (19%) differed from the most common pattern, with either a variation of the position or number of tendon slips at the MCP

joint.

Other anatomic variations in the EIP have been

described by Caudwell and colleagues, including double

tendon slips, an accessory slip to the long finger, and slips

to the index finger and thumb (60). An anomalous junctura

tendinum has been identified between the EPL and EDC

(61). Gonzalez and associates also studied the extensor tendons to the small finger in 50 specimens and noted that the

EDC was present in 35, and of those hands without an

EDC, 12 had a junctura tendinum present that went to the

small finger (23). However, three hands lacked both EDC

and juncturae. In these three hands, the EDM was represented by a single slip in two and a double slip in one. The

authors cautioned that if the entire (one or both slips, as the

case might be) EDM were used as a transfer in the absence

of both the EDC and juncturae, loss of extension would

occur in the small finger. In the 50 hands, the EDM was

most often (84%) represented by 2 slips; in 10% by a sinFIGURE 10.103. Extensor digitorum brevis manus (EDBM). A: Artist’s depiction of type I EDBM

[after Ogura et al. (58)]. B: Intraoperative photograph of type I EDBM before excision.

A B

gle slip; and in 6% by a triple slip. The authors also noted

that only 22 of the specimens had either an attachment of

the EDM to the abductor tubercle on the proximal phalanx

(10 hands) or an unbalanced ulnar slip of the EDQP (12

hands), which would account for Wartenberg’s sign in ulnar

nerve dysfunction. This 44% incidence would explain why

Wartenberg’s sign is not always present even in complete

lacerations of the ulnar nerve (23,62).

Clinical Significance

Knowledge of the usual as well as the possible variations,

including multiplicity, in the extensor tendons is useful in

the identification and repair of these structures as well as in

their use in reconstructive procedures.

Accessory Tendons from the Radial Wrist

Extensors

In addition to the extensor carpi radialis intermedius

(ECRI) musculotendinous units, both Wood and Albright

and Linburg noted the presence of accessory tendons from

the radial wrist extensors (63,64) (Fig. 10.104).

Wood noted 41 such tendons originating from the

ECRB and inserting with the ECRL on the index

metacarpal. Twenty-nine tendons originated from the

ECRL and inserted on the middle finger metacarpal with

the ECRB, and 24 tendons arose from the ECRL and

inserted alongside the normal tendon at the index finger

metacarpal. Only seven tendons originated from the ECRB

and inserted on the middle finger metacarpal. In two arms,

the ECRL and ECRB shared a common tendon that

inserted on both the index and middle finger metacarpal.

Clinical Significance

Wood’s study indicates that the ECRI or accessory tendons

are worth looking for, especially in patients with quadriplegia, because they can be used as transfers for thumb opposition, to motor the flexor pollicis longus or the EPL. Wood

noted that there is a fairly high incidence of bilateral variations of this type, and that 12% of individuals have a good

ECRI tendon and approximately 36% have at least one and

sometimes several accessory tendons that might be available

for transfer (63). Albright and Linburg not only emphasized the usefulness of the ECRI and accessory tendons as

transfers in tetraplegia but also noted the importance and

high incidence (35%) of cross-connections between the

ECRB and ECRL (64). They noted that identification and

release of these interconnections was important if either of

these tendons were to be used as transfers because failure to

do so might result in loss of independent excursion in the

transfer and thus possible failure of the transfer. These interconnections usually were found under the outcropping

664 Regional Anatomy

muscles to the thumb and often were difficult to detect

because they blended into the major tendons except when

traversing from one to another (64).

REFERENCES

1. Williams PL. Gray’s anatomy, 38th ed. New York: Churchill Livingstone, 1996.

2. Abrams RA, Brown RA, Botte MJ. The superficial branch of the

radial nerve: an anatomic study with surgical implication. J Hand

Surg [Am] 17:1037–1041, 1992.

FIGURE 10.104. Extensor carpi radialis intermedius (ECRI). The

most common origin and insertion of this anomalous forearm

muscle are shown.

3. Lucas GL. The pattern of venous drainage of the digits. J Hand

Surg [Am] 9:448–450, 1984.

4. Zook EG, Van Beek AL, Russell RC, et al. Anatomy and physiology of the perionychium: a review of the literature and

anatomic study. J Hand Surg[Am] 5:528–536, 1980.

5. Zook EG, Brown RE. The perionychium. In: Green DP, ed.

Operative hand surgery, 4th ed. New York: Churchill Livingstone,

1999:1353–1380.

6. Moss SH, Schwartz KS, von Drasek-Ascher G, et al. Digital

venous anatomy. J Hand Surg [Am] 10:473–482, 1985.

7. Smith DO, Oura C, Kimura C, et al. The distal venous anatomy

of the finger. J Hand Surg [Am] 16:303–307, 1991.

8. Matloub HS, Strathy KM, Sanger JR, et al. Venous anatomy of

the thumb. J Hand Surg [Am] 16:1063–1068, 1991.

9. Simons P, Coleridge Smith P, Lees WR, et al. Venous pumps of

the hand: their clinical importance. J Hand Surg [Br]

21:595–599, 1996.

10. Lavizari E, Ottolini V. Etude radiologique de la circulation veineuse

du membre superieur (sujet normal). Paris: Masson et Cie, 1958:

1–7.

11. Palmer AK, Skahen JR, Werner FW, et al. The extensor retinaculum of the wrist: an anatomical and biomechanical study. J

Hand Surg [Br] 10:11–16, 1985.

12. Taleisnik J, Gelberman RH, Miller BW, et al. The extensor retinaculum at the wrist. J Hand Surg [Am] 9:495–501, 1984.

13. Kline DM, Katzman BM, Mesa JA, et al. Histology of the extensor retinaculum of the wrist and the ankle. J Hand Surg [Am]

24:799–802, 1999.

14. Lister GD. Reconstruction of pulleys employing the extensor

retinaculum. J Hand Surg [Am] 4:461–464, 1979.

15. Kaplan EB. Anatomy, injuries and treatment of the extensor apparatus of the hand and fingers. Clin Orthop 13:24–41, 1959.

16. Cusenz BJ, Hallock GG. Multiple anomalous tendons of the

fourth dorsal compartment. J Hand Surg [Am] 11:263–264,

1986.

17. Schenck RR. Variations of the extensor tendons of the fingers:

surgical significance. J Bone Joint Surg Am 46:103–110, 1964.

18. von Schroeder HP, Botte MJ. Anatomy of the extensor tendons

of the fingers: variations and multiplicity. J Hand Surg [Am] 20:

27–34, 1995.

19. Slattery PG. The dorsal plate of the proximal interphalangeal

joint. J Hand Surg [Br] 15:68–73, 1990.

20. von Schroeder HP, Botte MJ, Gellman H. Anatomy of the juncturae tendinum of the hand. J Hand Surg [Am] 15:595–602,

1990.

21. Nichols HM. Manual of hand injuries, 2nd ed. Chicago: Year

Book, 1960:180–181, 191.

22. von Schroeder HP, Botte MJ. The functional significance of the

long extensors and juncturae tendinum in finger extension. J

Hand Surg [Am] 18:641–647, 1993.

23. Gonzalez MH, Weinzweig N, Kay T, et al. Anatomy of the extensor tendons to the index. J Hand Surg [Am] 21:988–991, 1996.

24. Kitano K, Tada K, Shibata T, et al. Independent index extension

after indicis proprius transfer: excision of juncturae tendinum. J

Hand Surg [Am] 21:992–996, 1996.

25. Eaton RG. The extensor mechanism of the fingers. Bull Hosp

Joint Dis 30:39–47, 1969.

26. Rayan GM, Murray D. Classification and treatment of closed

sagittal band injuries. J Hand Surg [Am] 19:590–594, 1994.

27. Young CM, Rayan GM. The sagittal band: anatomic and biomechanical study. J Hand Surg [Am] 25:1107–1113, 2000.

28. Harris C Jr, Rutledge GL Jr. The functional anatomy of the

extensor mechanism of the finger. J Bone Joint Surg Am 54:

713–726, 1972.

29. Landsmeer JMF. The anatomy of the dorsal aponeurosis of the

human finger and its functional significance. Anat Rec 104:31,

1949.

30. Micks JE, Reswick JB. Confirmation of differential loading of

lateral and central fibers of the extensor tendon. J Hand

Surg[Am] 6:462–467, 1981.

31. Tubiana R. Surgical repair of the extensor apparatus of the fingers. Surg Clin North Am 48:1015–1031, 1968.

32. McFarlane RM, Hampole MK. Treatment of extensor tendon

injuries of the hand. Can J Surg 16:366–375, 1973.

33. Moore JR, Weiland AJ, Valdata L. Independent index extension

after extensor indicis proprius transfer. J Hand Surg [Am]

12:232–236, 1987.

34. Noorda RJP, Hage JJ, de Groot PJM, et al. Index finger extension

and strength after extensor indicis proprius transfer. J Hand Surg

[Am] 19:844–849, 1994.

35. Wolfram-Gabel R, Sick H. Vascular networks of the periphery of

the fingernail. J Hand Surg [Br] 20:488–492, 1995.

36. Hashimoto R. Experimental study on histogenesis of the nail and

its surrounding tissues. Niigata Med J 82:254, 1971.

37. Shum C, Bruno RJ, Ristic S, et al. Examination of the anatomic

relationship of the proximal germinal nail matrix to the extensor

tendon insertion. J Hand Surg [Am] 25:1114–1117, 2000.

38. Pratt DR. Exposing fractures of the proximal phalanx of the finger through the dorsal extensor apparatus. Clin Orthop 15:

22–26, 1959.

39. Evans RB. Therapeutic management of extensor tendon injuries.

Hand Clin 2:157–169, 1986.

40. Kaplan EB. Functional and surgical anatomy of the hand, 2nd ed.

Philadelphia: JB Lippincott, 1965.

41. Warren RA, Kay NRM, Norris SH. The microvascular anatomy

of the distal digital extensor tendon. J Hand Surg [Br] 13:

161–163, 1988.

42. Souter WA. The boutonniere deformity: a review of 101 patients

with division of the central slip of the extensor expansion of the

fingers. J Bone Joint Surg Br 49:710–721, 1967.

43. Elson RA. Rupture of the central slip of the extensor hood. J

Bone Joint Surg Br 68:229–231, 1986.

44. Rubin J, Bozentka DJ, Bora FW. Diagnosis of closed central slip

injuries. J Hand Surg [Br] 21:614–616, 1996.

45. McCue FC, Honner R, Johnson MD, et al. Athletic injuries of

the proximal interphalangeal joint requiring surgery. J Bone Joint

Surg Am 52:937–955, 1970.

46. Bowers WH, Wolf J, Bittinger S, et al. The proximal interphalangeal joint: I. an anatomic and biomechanical study. J Hand

Surg [Am] 5:79–88, 1980.

47. Bowers WH. The proximal interphalangeal joint volar plate: II. a

clinical study of hyperextension injury. J Hand Surg [Am]

6:77–81, 1981.

48. Stack HG. Muscle function in the fingers. J Bone Joint Surg Br

44:899, 1962.

49. Zancolli E. Structural and dynamic basis of hand surgery. Philadelphia: JB Lippincott, 1968.

50. Doyle JR. Boutonniere. In: Strickland JW, ed. The hand: master

techniques in orthopaedic surgery. Philadelphia: Lippincott-Raven,

1998.

51. Doyle JR. Extensor tendons: acute injuries. In: Green DP, ed.

Operative hand surgery, 4th ed. New York: Churchill Livingstone,

1999.

52. Elson RA. Dislocation of the extensor tendons of the hand:

report of a case. J Bone Joint Surg Br 49:324–326, 1967.

53. Ishizuki M. Traumatic and spontaneous dislocation of extensor

tendon of the long finger. J Hand Surg [Am] 15:967–972, 1990.

54. Kettelkamp DB, Flatt AE, Moulds R. Traumatic dislocation of the

long finger extensor tendon: a clinical, anatomical, and biomechanical study. J Bone Joint Surg Am 53:229–240, 1971.

10.2 Dorsal Hand 665

55. Ritts GD, Wood MB, Engber WD. Nonoperative treatment of

traumatic dislocations of the extensor digitorum tendons in

patients without rheumatoid disorders. J Hand Surg [Am] 10:

714–716, 1985.

56. Wheeldon FT. Recurrent dislocation of extensor tendons. J Bone

Joint Surg Br 36:612–617, 1954.

57. von Schroeder HP, Botte MJ. The extensor medii proprius and

anomalous extensor tendons to the long finger. J Hand Surg

[Am] 16:1141–1145, 1991.

58. Ogura T, Inoue H, Tanabe G. Anatomic and clinical studies of

the extensor digitorum brevis manus. J Hand Surg [Am] 12:

100–107, 1987.

59. Dostal GH, Lister GD, Hutchinson D, et al. Extensor digitorum

brevis manus associated with a dorsal wrist ganglion: a review of

five cases. J Hand Surg[Am] 20:35–37, 1995.

60. Caudwell EW, Anson BJ, Wright RR. The extensor indicis proprius muscle: a study of 263 consecutive specimens. Q Bull

Northwest Univ Med School 17:267–279, 1963.

61. Steichen JB, Petersen DP. Junctura tendinum between extensor

digitorum communis and extensor pollicis longus. J Hand Surg

[Am] 9:674–676, 1984.

62. Wartenberg R. A sign of ulnar nerve palsy. JAMA 112:1688, 1939.

63. Wood VE. The extensor carpi radialis intermedius tendon. J

Hand Surg [Am] 13:242–245, 1988.

64. Albright JA, Linburg RM. Common variations of the radial wrist

extensors. J Hand Surg[Am] 3:134–138, 1978.

666 Regional Anatomy

aAI

ANATOMIC SIGNS,

SYNDROMES, TESTS, AND

EPONYMS

Appendix

This Appendix is designed to supply the reader with a comprehensive array of anatomic signs, syndromes, tests, and

eponyms that may be encountered in the surgical literature.

The authors have sought succinctly to define or describe the

entity, along with its clinical relevance and relationship to

the underlying anatomy. These may be of practical as well

as historical interest. Original references have been given for

most of the items. Although some of this array appears elsewhere in the text, it is believed that the reader will benefit

from the convenience of having these items collected in one

place. The authors believe that this Appendix does have a

logical connection with surgical anatomy, and that at the

minimum, the review of such a collection of material may

provide the reader with a nocturnal soporific at the end of

a long day.

ADSON’S MANEUVER (ADSON’S TEST)

Definition

Adson’s maneuver is a provocative test used in the evaluation of thoracic outlet compression syndrome.

Technique

The patient is seated and the examiner palpates the radial

pulse with the patient’s arm dependent. The neck is turned

toward the side of the lesion and extended while a deep

breath is taken. The radial pulse is palpated. Diminution or

loss of pulse as well as reproduction of symptoms is considered a positive test.

Clinical Significance

This test is based on potential compression of neurovascular structures between the anterior and middle scalene muscles. This test also is known as the scalene test and may be

positive in normal patients.

References

Adson AW, Coffey JR. Cervical rib: a method of anterior approach for

relief of symptoms by division of the scalenus anticus. Ann Surg

85:839–857, 1927.

Atasoy E. Thoracic outlet compression syndrome. Orthop Clin

North Am 27:265–303, 1996.

Leffert RD. Thoracic outlet syndrome. In: Omer GE, Spinner M,

Van Beek AL, eds. Management of peripheral nerve problems, 2nd

ed. Philadelphia: WB Saunders, 1998:494–500.

ALLEN TEST

Definition

The Allen test is a clinical test used to evaluate the patency

of the arteries in a double arterial supply system. It can be

used at the wrist to evaluate the radial and ulnar arteries, and

in a digit to evaluate the radial and ulnar digital arteries.

Technique

In the hand, the test consists of simultaneous occlusion of the

radial and ulnar arteries while emptying the hand of blood by

the patient’s active flexion and extension of the digits. The

occlusion is then removed from either the radial or ulnar

artery and the extent and speed of return of circulation are

noted. The test is repeated on the second artery, and the

results noted. If one of the two arteries is occluded or if there

is no connection between the two arterial systems, the compromised circulation will be evident. In the digit, the blood is

“milked” from the digit, and both digital arteries are compressed and released in sequence, as with the test at the wrist.

An occlusion of a digital artery is evident by failure of the digit

to refill when the artery is released. A technical pitfall is failure

to apply sufficient pressure to the vessels, and at the wrist 11

pounds or greater is required to occlude the vessels.

Clinical Significance

The Allen test is useful in routine evaluation of the vasculature of the digits and hand and is particularly valuable in

preoperative assessment of the digits or hand that have

compromised circulation and in procedures that have the

potential for compromise of the circulation. It also is helpful in vascular evaluation after previous trauma. The timed

Allen test is considered to be positive if refill does not occur

within 15 seconds, and refill that occurs within 6 to 15 seconds is considered to represent delayed or partial refill.

References

Allen EV. Thromboangiitis obliterans: methods of diagnosis of

chronic occlusive arterial lesions distal to the wrist with illustrative

cases. Am J Med Sci 178:237–244, 1929.

Gelberman RH, Blasingame JP. The timed Allen test. J Trauma 21:

477–479, 1981.

Koman LA. Diagnostic study of vascular lesions. Hand Clin 1:

217–231, 1985.

Wilgis EFS. Special diagnostic studies. In: Omer GE, Spinner M, Van

Beek AL, eds. Management of peripheral nerve problems, 2nd ed.

Philadelphia: WB Saunders, 1998:77–81.

ANDRE-THOMAS SIGN

Definition

The Andre-Thomas sign is an unconscious attempt to

extend the fingers by tenodesis of the extensors through palmar flexion of the wrist.

Clinical Significance

This spontaneous maneuver is seen in ulnar nerve palsy

with claw deformity of the ring and small fingers. Wrist

flexion represents an effort to extend these fingers by means

of extensor tenodesis effect, but only increases the claw

deformity of these fingers.

References

Andre-Thomas T. Le tonus du poignet dans la paralysie du nerf

cubital. Paris Med 25:473–476, 1917.

Green DP, Hotchkiss RN, Pederson WC, eds. Green’s operative hand

surgery, 4th ed. New York: Churchill Livingstone, 1999.

Omer GW. Ulnar nerve palsy. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s operative hand surgery, 4th ed. New York:

Churchill Livingstone, 1999.

ARCADE OF FROHSE

Definition

The arcade of Frohse is the fibrous tissue proximal edge of

the supinator muscle in the proximal and volar aspect of the

forearm, and is 3 to 5 cm distal to Hueter’s interepicondylar line.

Clinical Significance

The proximal edge of the superficial layer of the supinator is fibrous, especially the lateral side. This fibrous tissue edge forms the arcade of Frohse, which may compress

the anterior radial nerve branches to the supinator as well

as the posterior interosseous nerve as they enter the

supinator.

References

Frohse F, Frankel M. Die Muskelen des menschlichen Armes. In:

Bardeleben K, ed. Handbuch der Anatomie des Menschen, vol 2, sec

2, part 2. Jena, Germany: Gustav Fischer Verlag KG, 1908.

Fuss FK, Wurzl GH. Radial nerve entrapment at the elbow: surgical

anatomy. J Hand Surg [Am] 16:742–747, 1991.

ARCADES OF STRUTHERS

Definition

In 1854, John Struthers, an anatomist in Edinburgh,

described a series of nine abnormal arcades in the arm.

Eight (I to VIII) were related to potential compression of

the median nerve/brachial artery, and one to the ulnar nerve

(I). Only two, or possibly three, of these arcades have been

found to be associated with clinical symptoms. A complete

compilation of these arcades is presented in Table 6.4. The

first six of the median nerve/brachial artery arcades are of

historical and anatomic interest, and at this time have no

reported clinical significance in terms of entrapment or

impingement of nerve or blood vessel. The following three

arcades are of clinical significance.

Arcade VII of Median Nerve/Brachial

Artery Type

Arcade VII (see Fig. 6.31) is characterized by an abnormal

proximal origin of the superficial head of the pronator teres

from the supracondylar ridge rather than the medial epicondyle. This high origin also may be related to the presence of a supracondylar process. This position results in lateral displacement of the neurovascular bundle and has the

potential for compression of the underlying median nerve

and brachial artery.

Arcade VIII of Median Nerve/Brachial

Artery Type

Arcade VIII (see Figs. 6.30 and 6.32) consists of a supracondylar process and ligament of Struthers that spans

between the supracondylar process and the medial epicondyle, thus creating an arcade that contains the median

nerve and brachial artery. The supracondylar process is a

hook-shaped projection of bone from the anteromedial

aspect of the distal humerus that arises 3 to 5 cm proximal

to the medial epicondyle and is 2 to 20 mm in length. Its

incidence is approximately 1%, and it is a rare cause of pressure on the underlying median nerve and brachial artery. If

the ligament of Struthers extends to the fibrous arch of the

two heads of the flexor carpi ulnaris as well as to the medial

epicondyle, it may produce compression of the median and

the ulnar nerve. Struthers’ ligament has been reported without the usually associated supracondylar process, and the

ligament alone may produce median nerve compression.

670 Appendix

Clinical Significance

These two median nerve/brachial artery arcades may be a

source of compression of these vital structures.

Arcade I of Ulnar Nerve Type

This is a potential site of entrapment of the ulnar nerve 8

cm proximal to the medial epicondyle, called the arcade of

Struthers. When the arcade is present, both the ulnar nerve

and the superior ulnar collateral vessels pass through it. In

a recent study of 25 arms, the arcade of Struthers was present in 68% of the arms. The arcade has a roof that faces

medially, formed by the deep investing fascia of the arm,

superficial muscle fibers from the medial head of the triceps, and the internal brachial ligament arising from the

coracobrachialis tendon. The floor, which is lateral, is

formed by the medial aspect of the humerus covered by

the deep muscular fibers of the medial head of the triceps.

The anterior border is the medial intermuscular septum

(see Fig. 7.23).

Clinical Significance

Although the arcade of Struthers is a recognized anatomic

entity, it is said to be a rare cause of ulnar nerve compression. However, Spinner and Kaplan (1976) showed that the

arcade can produce recurrent ulnar neuropathy after anterior transposition of the nerve because of tethering, and

thus recommended lysis of the arcade as part of the transposition. They also recommended lysis of the arcade when

mobilizing a lacerated ulnar nerve in the forearm to reduce

the gap in the nerve.

References

Al-Qattan MM, Murray KA. The arcade of Struthers: an anatomical

study. J Hand Surg [Br] 16:311–314, 1991.

Smith RV, Fisher RG. Struthers’ ligament: a source of median nerve

compression above the elbow. J Neurosurg 28:778–779, 1973.

Spinner M, Kaplan EB. The relationship of the ulnar nerve to the

medial intermuscular septum in the arm and its clinical significance. Hand 8:239–242, 1976.

Struthers J. On some points in the abnormal anatomy of the arm. Br

Foreign Med Chir Rev 14:170–179, 1854.

Vesley DG, Killian JT. Arcades of Struthers. J Med Assoc State Al

52:33–37, 1983.

BARTON’S FRACTURE

Definition

In 1838, Barton described a fracture of the dorsal articular margin of the distal radius characterized by a separated

dorsal fragment, containing a margin of articular cartilage

that displaces upward and proximally onto the dorsal surface of the radius. The fracture occurs from a fall onto the

outstretched hand with the hand forced into dorsiflexion,

pushing the carpus against the dorsal margin of the articular surface of the radius. A variation of this fracture also

was described that involved the volar articular margin of

the distal radius, secondary to a force applied against the

back of the hand. This is sometimes referred to as the

reverse Barton’s fracture. The term reverse Barton’s fractures

probably should be changed to “a Barton’s fracture involving the volar or anterior articular margin,” because it was

described in the original article. It was noted that,

although rare, the injury often occurred “in awkward

attempts to parry the blow from a fist, from pressure in

dense crowds and from falling on the back of the hand

whilst it is bent forward.”

Clinical Significance

This is an intraarticular fracture that, if significantly displaced, usually is treated with operative fixation to restore

the articular surface. In addition, with significant dorsal or

palmar displacement of the detached fragment, the carpus

follows the fragment, with resultant dorsal or palmar subluxation, respectively. Reduction of the carpus and operative fixation of the fragment usually are indicated.

References

Barton JR. Views and treatment of an important injury of the wrist.

Med Exam 1:365–368, 1838.

Barton JR. Views and treatment of an important injury of the wrist.

Am J Med Sci 26:249–253, 1839.

Schultz RJ. The language of fractures. Huntington, NY: RE Krieger,

1976.

BENNETT’S FRACTURE

Definition

Bennett’s fracture refers to an oblique intraarticular fracture

of the palmar aspect of the base of the thumb metacarpal in

which the smaller palmar fragment remains in its anatomic

position and the thumb metacarpal is displaced proximally

and dorsally.

Clinical Significance

The smaller fragment remains in place because of intact

trapeziometacarpal ligaments, whereas the metacarpal is

displaced proximally and dorsally owing to the deforming

force of the abductor pollicis longus, which attaches to the

dorsal base of the metacarpal. In addition, the adductor pollicis places an adduction force on the thumb metacarpal,

which tends to displace the base of the metacarpal radially.

These displacement forces currently are managed by internal fixation of the fracture.

Anatomic Signs, Syndromes, Tests, and Eponyms 671

References

Bennett EH. Fractures of the metacarpal bones: reports of the Dublin

Pathological Society. Dubl J Med Sci 73:72–75, 1882.

Bennett EH. On fracture of the metacarpal bone of the thumb. BMJ

2:12–13, 1886.

BOUVIER’S SIGN OR MANEUVER

Definition

Bouvier’s sign is the ability actively to extend the proximal

interphalangeal joints of the ring and small fingers in ulnar

nerve palsy when the metacarpophalangeal (MCP) joints

are passively stabilized in neutral by the examiner’s fingers.

Technique

The hyperextended proximal phalanges of the ring and

small fingers as seen in ulnar nerve claw deformity are repositioned in neutral by the examiner’s fingers. The patient is

then asked to extend the fingers.

Clinical Significance

Repositioning and stabilizing the patient’s hyperextended

ring and small finger proximal phalanges in cases of

interosseous muscle palsy (ulnar nerve palsy) allows the

extensor digitorum communis (EDC) to extend the interphalangeal joints. Bouvier’s maneuver demonstrates the role

of the interosseous muscles in stabilizing the MCP joints

during active extension of the fingers. This may be demonstrated on one’s own hand by simultaneously extending the

proximal phalanges and flexing the interphalangeal joints of

the ring and small fingers, and then pushing the proximal

phalanges into flexion. The fingers spontaneously extend if

maximum force is maintained in the EDC.

Reference

Bouvier F. Note sur un cas de paralysie de la main. Bull Acad Med

27:125, 1851.

BOWLER’S THUMB

Definition

Bowler’s thumb is an incontinuity neuroma of the ulnar

digital nerve of the thumb.

Clinical Significance

This incontinuity neuroma is due to external pressure from

the margin of the thumb hole in a bowling ball. It usually

involves the ulnar nerve and is characterized by pain, paresthesias, and a tender mass on the ulnar aspect of the proximal phalanx of the thumb. A thrombosed aneurysm of the

digital artery due to bowling also has been seen [Pons

(1983)]. A variation known as cherry pitter’s thumb has been

described by Viegas (see later).

References

Dobyns JH, O’Brien ET, Linscheid RL, et al. Bowler’s thumb: diagnosis and treatment. A review of seventeen cases. J Bone Joint

Surg Am 54:751, 1972.

Pons RK. Bowler’s thumb [Letter]. J Hand Surg[Am] 1983;8:630.

BOYES TEST

Definition

This is a test for diagnosis of boutonniere deformity.

Technique

When the proximal interphalangeal joint is held in extension by the examiner, it normally is possible for the patient

actively to flex the distal interphalangeal (DIP) joint. However, if the central slip is ruptured, there is increasing difficulty in actively flexing the DIP joint.

Clinical Significance

This test becomes positive only when the ruptured central slip has retracted and the lateral bands have migrated

volarly and shortened. It is the contracted and shortened

lateral bands that prevent normal active flexion of the

DIP joint. Although a reliable test for boutonniere deformity, it may not be positive in the early stages of the

deformity. Early diagnosis may be achieved by the Elson

test (see later).

References

Boyes J. Bunnell’s surgery of the hand, 5th ed. Philadelphia: JB Lippincott, 1970:439–442.

Elson RA. Rupture of the central slip of the extensor hood of the finger: a test for early diagnosis J Bone Joint Surg Br 68:229–231,

1986.

Rubin J, Bozentka DJ, Bora FW. Diagnosis of closed central slip

injuries. J Hand Surg [Br] 21:614–616, 1996.

BREWERTON VIEW (RADIOGRAPH)

Definition

This tangential radiographic view of the metacarpal heads

was originally described as being useful for demonstration

of erosive changes in the metacarpal neck and head in

rheumatoid arthritis; it also is a valuable aid in detecting

fractures or avulsions of ligamentous insertions in the

region of the metacarpophalangeal (MCP) joint.

672 Appendix

Technique

The radiographs are made with the palm up, the fingers flat

on the x-ray plate, the MCP joints flexed to 65 degrees, and

the x-ray beam angled from a point 15 degrees to the ulnar

side of the hand.

Clinical Significance

The Brewerton view may detect avulsion fractures of the

metacarpal head and neck that standard anteroposterior,

oblique, and lateral radiographs fail to detect.

References

Brewerton DA. A tangential radiographic projection for demonstrating involvement of the metacarpal heads in rheumatoid arthritis.

Br J Radiol 40:233, 1967.

Lane CS. Detecting occult fractures of the metacarpal head: the Brewerton view. J Hand Surg[Am] 2:131–133, 1977.

BUNNELL’S “O” TEST FOR ULNAR NERVE

PALSY

Definition

The thumb fails to produce a good circle or “O” when it

opposes the tip of the index finger.

Clinical Significance

Failure to form an “O” or circle between the thumb and

index finger indicates ulnar nerve palsy due to paralysis of

the adductor pollicis and deep head of the flexor pollicis

brevis. These muscles ordinarily stabilize the thumb metacarpophalangeal joint in flexion during pinch.

Reference

Bunnell SB. Surgery of the hand. Philadelphia: JB Lippincott, 1944:

247.

BUNNELL’S “SCRAPE” TEST FOR ULNAR

NERVE PALSY

Definition

The extended thumb cannot scrape across the extended fingers and palm, but rather leaves (abducts away from) the

palm at the radial side of the index finger.

Clinical Significance

This finding indicates ulnar nerve palsy associated with loss

of function of the adductor, which normally would keep the

thumb closely applied to the palm and thus allow it to

scrape or remain closely applied to the palm during flexion.

Reference

Bunnell SB. Surgery of the hand. Philadelphia: JB Lippincott, 1944:

247.

CANNIEU-RICHE ANASTOMOSIS

Definition

This anastomosis, in its classic form, is between the motor

branch of the ulnar nerve and the motor branch of the

median nerve in the proximal and radial palm. It was

described by Cannieu in 1896 and 1897 and by Riche in

1897.

Anatomy

The classic description is of an anastomosis between a

ramus of the recurrent branch of the median nerve supplying the superficial head of the flexor pollicis brevis (FPB)

and the anastomotic ramus of the deep branch of the ulnar

nerve supplying the deep head of the FPB. The anastomotic

branch is present between the two heads of the adductor

pollicis and then circles round the flexor pollicis longus

(FPL) tendon on its lateral side. Variations include (a) a separate branch of the median nerve to the superficial head of

the FPB that sends a branch to the anastomosis; in this

type, the anastomosis can be located either on the surface of

or deep in the FPB; (b) the anastomosis may be with one or

two digital nerve branches of the thumb from the median

nerve; in this type the anastomosis is located medial to the

tendon of the FPL, and sometimes a double or triple anastomosis may be found; (c) an anastomosis may occur

between one of the branches of the digital nerve to the

thumb and the branch to the adductor pollicis, coming

from the deep ulnar nerve; this anastomosis is medial to the

FPL tendon, deep in the adductor pollicis, and there is no

ulnar innervation to the deep head of the FPB; and (d) a

deep branch of the ulnar nerve may pass through and innervate the first lumbrical on its way to anastomose with the

digital branch to the index.

Clinical Significance

The FPB, in addition to its classic anatomic ability to flex

the metacarpophalangeal joint, also can abduct and

pronate the first metacarpal. Double (from median and

ulnar) innervation of the FPB muscle may explain a

nonanatomic persistence of function after median or

ulnar nerve injury. Adequate pinch may be retained and

Froment’s sign may be minimal or absent in the ulnar

nerve–injured patient if the deep head of the FPB has

median nerve innervation; in median nerve injury, opponensplasty may not be required if the superficial head of

the FPB is ulnar nerve innervated.

Anatomic Signs, Syndromes, Tests, and Eponyms 673

References

Cannieu A. Recherche sur l’innervation de l’eminence thenar par le

cubital. J Med Bord 377–379, 1896.

Cannieu A. Note sur une anastomose entre le branche profunde du

cubital et le median. Bull Soc Anat Physiol Horm Pathol Bord

17:339–342, 1897.

Riche P. Le nerf cubital et les muscles de l’eminence thenar. Bull Mem

Soc Anat Paris 251–252, 1897.

CHASSAIGNAC’S TUBERCLE (CAROTID

TUBERCLE)

Definition

Chassaignac’s tubercle is the prominent anterior tubercle of

the transverse process of C6.

Clinical Significance

Chassaignac’s tubercle is a useful landmark in the administration of stellate ganglion blocks.

Reference

Atasoy E, Kleinert HE. Surgical sympathectomy and sympathetic

blocks for the upper and lower extremities, and local and plexus

levels. In: Omer GE, Spinner M, Van Beek AL, eds. Management

of peripheral nerve problems, 2nd ed. Philadelphia: WB Saunders,

1998:157–171.

CHERRY PITTER’S THUMB

Definition

Cherry pitter’s thumb is digital nerve compression or neuritis from repetitive external trauma to the thumb digital

nerves in cherry pitters. It is characterized by neuritic symptoms of pain and numbness, with possible positive percussion test of the involved digital nerve.

Clinical Significance

This condition is similar to the Bowler’s thumb, and both

conditions are secondary to repetitive external trauma.

Reference

Viegas SF, Torres FG. Cherry pitter’s thumb: case report and review

of the literature. Orthop Rev 18:336, 1989.

CLELAND’S LIGAMENTS

Definition

These structures are retaining skin ligaments that stabilize the

skin during flexion and extension of the fingers and thumb.

Anatomy

Based on Milford’s dissections, they arise from the proximal

interphalangeal (PIP) joint on each side of the finger and

interphalangeal joint of the thumb. They are dense, fibrous

bundles that diverge from their origin to insert into the skin.

The fibers are arranged in two planes and form a structure

somewhat like a cone. They are dorsal to the neurovascular

bundle and are arranged proximal and distal to the transverse

retinacular ligament in the finger near its palmar insertion.

The largest bundle originates from the lateral margin of the

middle phalanx over its proximal fourth, from the joint capsule of the PIP joint, and from the flexor tendon sheath.

These fibers are strong, project in straight lines, and fan out

to insert in an area of skin larger than their origin, but all

fibers insert proximal to the distal interphalangeal (DIP)

joint. The most dorsal of the fibers become taut when the

PIP joint is flexed (lending some stability to the skin) because

of the fibers over the condyle of the proximal phalanx. The

most palmar fibers become taut with PIP joint extension,

with similar stability noted in the skin. The two distal bundles of this ligament originate from the DIP joint from the

bone and capsule, over a small 1- to 2-mm area just proximal

and distal to the joint. The strongest bundle of Cleland’s ligament in the thumb (the proximal) arises from the flexor tendon sheath just distal to the metacarpophalangeal joint and

then courses distally to insert into the adjacent skin. The distal two bundles arise at the interphalangeal joint from the

bone and capsule over a small area.

Clinical Significance

These structures stabilize the skin during flexion and extension of the digits. They may be pictured as tethers and outriggers to prevent undue movement of the soft tissue envelope about the underlying phalanges, in Cleland’s words,

“helping to retain the different parts of the integument in

the positions which they are adapted to occupy.”

References

Cleland J. On the cutaneous ligaments of the phalanges. J Anat Physiol 12:526–527, 1878.

Milford LW. Retaining ligaments of the hand. Philadelphia: WB Saunders, 1968.

CROSSED FINGERS TEST

Definition

This is a quick and reliable test to determine ulnar nerve

function.

Technique

The patient is asked to cross the long finger over the index

finger.

674 Appendix

Clinical Significance

This maneuver tests the function of the ulnar nerve–innervated first volar and the second dorsal interosseous muscles.

Inability to perform this maneuver indicates paralysis of these

muscles, as seen in ulnar nerve palsy. The chief usefulness of

the test is for screening patients with acute injuries for ulnar

nerve damage. The test’s specificity (not easily duplicated by

trick movements, and no anomalous innervation) and the

ease with which it can be demonstrated to the patient appear

to contribute to the test’s usefulness.

Reference

Earle AS, Vlastou C. Crossed fingers and other tests of ulnar nerve

motor function. J Hand Surg [Am] 5:560–565, 1980.

CHEIRALGIA PARAESTHETICA

See Wartenberg’s Syndrome.

CHAUFFEUR’S FRACTURE (BACKFIRE

FRACTURE, LORRY DRIVER’S FRACTURE)

Definition

This is an oblique intraarticular fracture of the distal radius

that extends from the articular surface to the lateral radial

metaphysis, separating the styloid from the shaft of the

radius. The fracture originally occurred from cranking a car,

in which a backfire forced the crank handle backward. The

fracture resulted from either the handle directly striking the

radial diaphysis or from forceful dorsiflexion and abduction

of the wrist.

Clinical Significance

The diagnosis may be delayed because of the minimal physical deformity and the fact that wrist edema may be the only

presenting sign. If displaced, this intraarticular fracture usually is treated optimally with operative fixation.

Reference

Schultz RJ. The language of fractures. Huntington, NY: RE Krieger,

1976.

COLLES’ FRACTURE

Definition

Colles’ fracture is a fracture of the distal radius with dorsal

comminution, dorsal angulation, dorsal displacement, and

radial shortening.

Clinical Significance

This most common wrist fracture in adults is manifested

clinically by a painful “silverfork” deformity that Colles

described in 1814, noting that “The carpus and base of the

metacarpus appear to be thrown backward so much as on

first view, to excite a suspicion that the carpus is dislocated.”

References

Colles A. On the fracture of the carpal extremity of the radius. Edinburgh Med Surg J 10:182–186, 1814.

Colles A. On the fracture of the carpal extremity of the radius. Med

Classics 4:1038–1042, 1940.

DE QUERVAIN’S DISEASE

Definition

de Quervain’s disease is stenosing tenosynovitis of the

abductor pollicis longus (APL) and extensor pollicis brevis

(EPB) tendons as they pass through a synovial-lined

fibroosseous tunnel at the styloid process of the radius at the

wrist. Signs of inflammation, manifested by swelling and

tenderness over the radial styloid, sometimes are accompanied by crepitus with motion of the thumb. A confirmatory

diagnostic test is performed by grasping the thumb and

abducting the wrist (the Finkelstein test; see the entry on

Finkelstein’s Test for details of this maneuver).

Clinical Significance

This inflammatory disorder often is relieved by conservative

treatment, including rest to the thumb and wrist by splinting, and injection of steroids into the involved sheath.

Surgery, in the form of release of the sheath of the APL and

EPB, is reserved for those patients who do not respond to

conservative treatment. Critical anatomic features relate to

the close proximity of branches of the radial sensory nerve

that are at risk and failure to recognize the fact that the EPB

may be in a separate fibroosseous tunnel. Failure to release

the EPB may be associated with an incomplete recovery.

Reference

de Quervain F. Uber eine Form von chronischer Tendovaginitis. Corresp Blatt Schweiz Aerzte 25:389–394, 1895.

DE QUERVAIN’S FRACTURE

Definition

This is a transscaphoid, perilunate fracture dislocation of

the wrist in which the lunate and proximal pole of the

scaphoid dislocate as a unit palmarward, while the distal

Anatomic Signs, Syndromes, Tests, and Eponyms 675

pole of the scaphoid and the remainder of the carpus

remain in relatively normal axial alignment.

Clinical Significance

Although this injury may be managed by closed reduction,

many surgeons choose to perform open reduction and

internal fixation because of the potential for delayed union

or nonunion of the scaphoid.

References

de Quervain F. Spezielle chirurgische Diagnostik fur Studierende und

Aerzte. Leipzig: FCW Vogel, 1907.

de Quervain F. Clinical surgical diagnosis for students and practitioners,

4th ed. Snowman J, translator. New York: William Wood, 1913.

DUCHENNE’S SIGN

Definition

Duchenne’s sign is claw deformity of the ring and small fingers. The small finger cannot be adducted to the ring finger.

There is loss of ability to play high notes on the violin

because of inability to reach and press appropriately on the

strings.

Clinical Significance

This classic sign of ulnar nerve palsy is due to paralysis of the

intrinsic muscles in the presence of normal function of the

extrinsic extensors and flexors. The unopposed action of the

extensor digitorum communis results in hyperextension of

the proximal phalanx, while the extrinsic flexors produce

flexion of the proximal and distal interphalangeal joints,

which results in the claw deformity. In high ulnar nerve

lesions with associated paralysis of the ring and small finger

profundus, the claw deformity may be diminished. An

unconscious effort to extend the fingers by tenodesing the

extensor tendons by palmar flexion of the wrist increases the

deformity and is called the Andre-Thomas sign (see earlier).

Loss of adduction of the small finger is due to denervation of

the ulnar-innervated third palmar interosseous, which

attaches to the radial base of the small finger proximal phalanx. The loss of ability to play high notes is due to loss of

function in the opponens digiti minimi and the flexor carpi

ulnaris that results in inability to flex and ulnar deviate the

wrist and thus to position the fingers over the strings. In addition, the diminished flexion arc of the clawed fingers prevents

appropriate contact of the fingertips with the strings.

Reference

Duchenne GBA. Physiology of motion [Physiologie des movements demontree a l’aide de l’experimentation electrique et de l’oberservation clinique

et applicable a l’etude des paralysies et des degenerations. 1867.]. Kaplan

EB, translator and ed. Philadelphia: WB Saunders, 1959.

DUPUYTREN’S CONTRACTURE

Definition

Dupuytren’s contracture is a thickening of the palmar and digital fascia, resulting in nodules, cords, and digital contracture.

Clinical Significance

Progressive flexion contracture of the fingers results in significant loss of function, and palmar and digital fasciectomy

is commonly performed.

Reference

Dupuytren G. De la retraction des doigts par suite d’une affection de

l’aponevrose palmaire—description de la maladie—operation

chirurgicale qui convient dans ce cas. Compte rendu de la clinique

chirurgicale de l’Hotel Dieu par MM les docteurs Alexandre Paillard et Marx. J Univers Hebdom Med Chir Prat Inst Med

5:349–365, 1831.

EGAWA SIGN

Definition

The Egawa sign is the inability of the flexed long finger to

abduct radioulnarly or to rotate at the metacarpophalangeal

joint.

Clinical Significance

This is a sign of ulnar nerve dysfunction and is due to paralysis of the interosseous muscles. Flexion of the finger prevents

the extensor digitorum communis from abducting the finger.

References

Egawa T. Electromyographic studies on finger motion. J Osaka Univ

Med School 11:1739–1758, 1959.

Mannerelt L. Studies on the hand in ulnar nerve paralysis. Acta

Orthop Scand Suppl 87:1–176, 1966.

ELBOW FLEXION TEST

Definition

This is a provocative test for diagnosing compression neuropathy of the ulnar nerve at the elbow.

Technique

The test is performed by fully flexing the elbow for 1

minute. A positive test is manifested by paresthesias in the

ulnar nerve distribution.

676 Appendix

Clinical Significance

This test may be useful in the diagnosis and staging [Dellon

(1989)] of ulnar nerve compression at the elbow. Rayan et

al. (1992) found that the test may be positive in 10% to

13% of the normal population based on various positions

of the wrist and shoulder.

References

Dellon AL. Review of treatment results for ulnar nerve entrapment at

the elbow. J Hand Surg [Am] 14:688–700, 1989.

Rayan GM, Jensen C, Duke J. Elbow flexion test in the normal population. J Hand Surg [Am] 17:86–89, 1992.

Wadsworth T. The external compression syndrome of the ulnar nerve

at the cubital tunnel. Clin Orthop 124:189–204, 1977.

ELSON TEST

Definition

This is a test for the early diagnosis of boutonniere deformity.

Technique

The finger to be examined is flexed comfortably to a right

angle at the proximal interphalangeal (PIP) joint over the

edge of a table and firmly held in place by the examiner.

The patient is then asked to extend the PIP joint against

resistance. Any pressure felt by the examiner over the middle phalanx can be exerted only by an intact central slip.

Further proof is that the distal interphalangeal (DIP) joint

remains flail during the effort because the competent central slip prevents the lateral bands from acting distally. In

the presence of a complete rupture of the central slip, any

extension effort perceived by the examiner is accompanied

by rigidity at the DIP joint with a tendency to extension.

This is produced by the extensor action of the lateral bands.

Note: This test will not demonstrate the presence of a partial rupture of the central slip, and it may be impeded by

pain or lack of patient cooperation. Consideration may be

given to nerve block for pain relief as indicated.

Clinical Significance

Early diagnosis of boutonniere deformity gives the best

chance of a satisfactory outcome. Boyes test becomes positive only at a late stage. In a study that used various published clinical tests to diagnose an early boutonniere, only

the Elson test was said to be reliable. The Elson test relies

on abnormal tone between the PIP and DIP joints. Normally, with the PIP joint blocked in flexion, there is limited

active extension of the DIP joint. Harris and Rutledge

demonstrated that the lateral bands are held distally by the

central slip, and because of check-rein effect, the extensor

mechanism is unable to extend the DIP joint. But, with disruption of the central slip and loss of the check-rein effect,

extension of the DIP can occur by tightening the dorsal

apparatus. On performing the Elson test with a ruptured

central slip, attempted active extension of the finger with

the PIP joint held in flexion increases the rigidity of the

DIP joint.

References

Elson RA. Rupture of the central slip of the extensor hood of the finger: a test for early diagnosis. J Bone Joint Surg Br 68:229–231,

1986.

Harris C, Rutledge GL. The functional anatomy of the extensor

mechanism of the finger. J Bone Joint Surg Am 54:713–726,

1972.

Rubin J, Bozentka DJ, Bora FW. Diagnosis of closed central slip

injuries. J Hand Surg [Br] 21:614–616, 1996.

ERB-DUCHENNE PALSY (PLEXOPATHY)

Definition

This is an upper brachial plexus palsy, usually involving the

C5 and C6 (and possibly C7) nerve roots.

Clinical Significance

The patient demonstrates paralysis of the supraspinatus,

infraspinatus, rhomboids, deltoid, biceps, and brachialis,

and weakness of the pectoralis major, triceps, and extensor

carpi radialis longus and brevis that results in loss of shoulder external rotation, elbow flexion, forearm supination,

and wrist extension. The upper extremity assumes a position of shoulder adduction and internal rotation, elbow

extension, forearm pronation, and wrist flexion (the socalled waiter’s tip position).

References

Duchenne GB. De l’electrisation localisee et de son application a la

pathologie et a la therapeutique, 3rd ed. Paris: Bailliere, 1872:357.

Erb W. On a characteristic site of injury in the brachial plexus [translated by Brody and Wilkins]. Arch Neurol 21:443, 1969.

ESSEX-LOPRESTI FRACTURE

Definition

An Essex-Lopresti fracture is a comminuted fracture of the

radial head associated with longitudinal injury of the forearm interosseous membrane that is characterized by migration of the radial shaft, disruption of the distal radioulnar

joint, and relative positive ulnar variance. Fracture of the

radial head with dislocation of the distal radioulnar joint

was first described by Curr and Coe in 1946.

Anatomic Signs, Syndromes, Tests, and Eponyms 677

Clinical Significance

Comminuted fractures of the radial head require careful

assessment of the interosseous membrane (for tenderness)

and physical and radiographic examination of the wrist.

The lesion may be present acutely, or may develop progressively after excision of the comminuted radial head.

References

Curr JF, Coe WA. Dislocation of the inferior radio-ulnar joint. J Bone

Joint Surg 34:74–77, 1946.

Essex-Lopresti P. Fractures of the radial head with distal radioulnar

dislocation. J Bone Joint Surg Br 33:244–247, 1951.

EXTENSOR INDICIS PROPRIUS SYNDROME

Definition

Extensor indicis proprius (EIP) syndrome is a type of

tenosynovitis caused by the extension of the musculotendinous junction of the EIP into the rigid confines of the

fourth extensor compartment. This syndrome usually manifests itself as dorsal wrist pain that is localized to the musculotendinous junction of the EIP. The pain is aggravated

by use of the wrist and hand, usually during strenuous

activities. Symptoms are localized to the dorsum of the

wrist over the fourth dorsal compartment and are associated

with localized swelling, tenderness, and often crepitus. The

swelling usually diminishes with wrist extension and is most

noticeable during wrist flexion. Resisted extension of the

index finger metacarpophalangeal joint with the wrist in

flexion usually produces dorsal radial wrist pain in this syndrome.

Clinical Significance

Although this is a rare form of tenosynovitis compared with

trigger digits or de Quervain’s tenosynovitis, it should be

added to the list of causes of wrist pain. This syndrome may

be the cause of dorsal wrist pain sometimes seen with a dorsal radial ganglion.

References

Ritter WA, Inglis AE. The extensor indicis proprius syndrome. J Bone

Joint Surg Am 51:1645–1648, 1969.

Spinner M, Olshansky K. The extensor indicis proprius syndrome: a

clinical test. Plast Reconstr Surg 51:134–138, 1973.

EXTENSOR PLUS SYNDROME OR TEST

Definition

This condition is characterized by the inability simultaneously to flex the metacarpophalangeal (MCP) and proximal

interphalangeal (PIP) joints, although individually the

joints can be flexed.

Technique

The examiner attempts passively and simultaneously to flex

the MCP and PIP joints. If both joints can be flexed normally, the test is negative. If flexion of the MCP joint is

associated with absent or limited flexion of the PIP joint,

the test is positive and is confirmed by noting improved or

complete flexion of the PIP joint with hyperextension of

the MCP joint.

Clinical Significance

A positive result in this test indicates shortening or adherence of the extensor mechanism proximal to the MCP

joint.

Reference

Kilgore ES Jr, Graham WP, et al. The extensor plus finger. Hand

7:159–165, 1975.

FINKELSTEIN’S TEST

Definition

A diagnostic test for evaluation of stenosing tenosynovitis of

de Quervain.

Technique

The patient’s thumb is grasped by the examiner and the

hand quickly abducted (bent ulnarward). The test is inappropriately performed by placing the thumb in the palm

followed by wrist abduction because this often may produce

pain (a false-positive result) even in a normal wrist [Elliott

(1992)]. The latter technique was described in 1927 by

Eichhoff, and although used to diagnose stenosing tenosynovitis, probably is not as reliable as Finkelstein’s test.

Clinical Significance

The production of pain over the radial styloid by this

maneuver is the result of stretching inflamed tendons

(abductor pollicis longus and extensor pollicis brevis) in the

first extensor compartment and is a pathognomonic sign of

de Quervain’s tenosynovitis.

References

Eichhoff E. Zur Pathogenese der Tenovaginitis Stenosans. Bruns

Beitage Zur Klin Chir 139:746–755, 1927.

Elliott BG. Finkelstein’s test: a descriptive error that can produce a

false positive. J Hand Surg [Br] 17:481–482, 1992.

678 Appendix

Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J

Bone Joint Surg 12:509–540, 1930.

FROMENT’S SIGN

Definition

Froment’s sign is the occurrence of hyperflexion of the interphalangeal joint of the thumb during key pinch between the

pulp of the thumb and the radial side of the index finger.

Technique

The classic photograph of the technique shows the comparative posture of the two thumbs with the patient pinching

the margin of a newspaper.

Clinical Significance

Loss of pinch force due to denervation of the ulnar-innervated adductor pollicis results in compensatory force from

the flexor pollicis longus, which is manifested by hyperflexion of the thumb interphalangeal joint. Hyperextension at

the metacarpophalangeal joint also may occur. Froment’s

sign is a classic indicator of ulnar nerve palsy.

References

Froment MJ. La paralysie de l’adducteur du ponce et le signe de la

prehension. Rev Neurol 28:1236–1240, 1914–15.

Froment MJ. La prehension dan les paralysies du nerf cubital et le

signe du ponce. Presse Med 23:409, 1915.

GALEAZZI FRACTURE

Definition

This is a fracture of the radius at or near the junction of the

middle and distal thirds that is associated with subluxation

or dislocation of the distal ulna.

Historical

The French, as early as 1929, referred to this injury as a

reverse Monteggia fracture [Valande (1929)]. It also has

become known as the Piedmont fracture because of a report

on a series of cases from members of the Piedmont

Orthopaedic Society published by Hughston in 1957.

Clinical Significance

Galeazzi (1934) observed that the ulnar subluxation may be

present initially or may develop gradually during treatment.

Hughston (1957) noted four main deforming factors that

might contribute to loss of reduction of this complex fracture.

References

Galeazzi R. Ueber ein besonderes Syndrom bei Verltzunger im Bereich der Unterarmknochen. Arch Orthop Unfallchir 35:557–562,

1934.

Hughston JC. Fractures of the distal radial shaft: mistakes in management. J Bone Joint Surg Am 39:249–264, 1957.

Valande M. Luxation en arriere de cubitus avec fracture de la diaphse

radiale. Bull Mem Soc Nat Chir 55:435–437, 1929.

GAMEKEEPER’S THUMB

Definition

Gamekeeper’s thumb is attenuation of the ulnar collateral

ligament (UCL) of the metacarpophalangeal (MCP) joint

of the thumb due to chronic stress on the UCL that eventually results in instability of the ulnar side of the thumb

MCP joint.

Clinical Significance

This deformity is the result of repeated injury or chronic

stress placed on the UCL, in contrast to the acute rupture

or avulsion of the UCL. The term gamekeeper’s thumb has

been used however to describe both acute and chronic

injuries to the UCL of the thumb MCP joint. Milch (1929)

first described chronic instability in this region in 1926;

Campbell (1955) described chronic UCL instability in

Scottish gamekeepers whose method of killing rabbits was

by a sudden and forceful stretching of the animal’s neck,

which was fixed in the keeper’s first web space. Repetitive

forces eventually resulted in attenuation of the UCL head.

References

Campbell CS. Gamekeeper’s thumb. J Bone Joint Surg Br

71:148–149, 1955.

Milch H. Recurrent dislocation of the thumb: capsulorrhaphy. Am J

Surg 6:237–239, 1929.

GRAYSON’S LIGAMENTS

Definition

Grayson’s ligaments are retaining skin ligaments that are

palmar to the neurovascular bundles and pass from the skin

to the flexor tendon sheath.

Anatomy

Grayson (1941) reported that they were found in pairs at each

interphalangeal joint and that only the proximal pair of ligaments about the distal interphalangeal (DIP) joint could be

demonstrated with certainty. According to Grayson, those of

the proximal interphalangeal joint demonstrated two pairs,

with the proximal portion arising from the flexor sheath at the

Anatomic Signs, Syndromes, Tests, and Eponyms 679

distal third of the proximal phalanx and the distal pair arising

from the sheath over the proximal third of the middle phalanx. Milford (1968), in his comprehensive dissections of the

retaining ligaments of the digits, found that Grayson’s ligament was fragile and membranous in character and was

strongest at the middle three-fourths of the middle phalanx in

the finger and just proximal to the interphalangeal joint in the

thumb. Milford noted that the ligament originated from the

palmar aspect of the flexor tendon sheath and projected at

right angles (at variance with Grayson’s observation of an

oblique course) to the long axis of the finger.

Clinical Significance

Milford concluded that (a) Grayson’s ligament in the

human probably is strong enough to maintain the digital

vessels and nerves in place and prevent bowstringing when

the finger is flexed; and (b) clinically, along with Cleland’s

ligament, they formed a tube from the proximal aspect of

the finger to the DIP joint, in which the digital nerves and

vessels always can be found during surgical dissection.

References

Grayson J. The cutaneous ligaments of the digits. J Anat 75:164–165,

1941.

Milford LW. Retaining ligaments of the hand. Philadelphia: WB Saunders, 1968.

GUYON’S CANAL

Definition

Guyon’s canal, or the ulnar tunnel, is the space that the

ulnar nerve and artery traverse to gain entrance to the hand

from the forearm.

Anatomy

Guyon’s canal begins at the proximal edge of the palmar carpal

ligament and ends at or beyond the fibrous arch of the

hypothenar muscles [formed mainly by the flexor digiti minimi (FDM)]. Beginning from proximal to distal, the roof of

the canal is formed by the palmar carpal ligament, portions of

the palmar aponeurosis, and the palmaris brevis muscle. The

floor is formed by the transverse carpal ligament (TCL), the

pisohamate and pisometacarpal ligaments, and the FDM. The

ulnar wall is composed of the flexor carpi ulnaris, the pisiform,

and the abductor digiti minimi. The radial wall is formed by

the tendons of the extrinsic flexors, the TCL, and the hook

process of the hamate.

Clinical Significance

Kuschner et al. (1988) divided Guyon’s canal into three

zones that they found to be useful for the localization and

correct prediction of the cause of ulnar neuropathy in the

canal (see discussion of Guyon’s canal and Table 10.9 in

Chapter 10). They concluded that their division of

Guyon’s canal into zones along with a careful history and

examination, including appropriate tests, would result in

a more accurate prediction of the cause of the ulnar

deficit.

References

Denman EE. The anatomy of the space of Guyon. Hand 10:69–76,

1978.

Guyon F. Note sur une disposition anatomique propre a la face

anterieure de la region du poignet et non encore decrite. Bull Soc

Anat Paris 6:184–186, 1861.

Kuschner SH, Gelberman RH, Jennings C. Ulnar nerve compression

at the wrist. J Hand Surg [Am] 13:577–580, 1988.

HAINES-ZANCOLLI TEST (THE RETINACULAR

PLUS TEST)

Definition

This is a test for contracture of the oblique retinacular ligament and displacement of the lateral bands as seen in the

boutonniere deformity.

Technique

The proximal interphalangeal (PIP) joint is held in extension and passive flexion of the distal interphalangeal joint

(DIP) is attempted. If passive flexion can be obtained, the

test is negative. If passive flexion is significantly limited or

not possible, the test is positive.

Clinical Significance

This test may be used as part of the evaluation process of

patients with the history of a “jammed finger” that presents with swelling and tenderness about the PIP joint. It

may aid in the detection of the anatomic precursors of the

boutonniere deformity (central slip disruption of the

extensor digitorum communis at the PIP joint and progressive palmar migration of the lateral bands). This test

may be used to determine the stage of progression of the

boutonniere deformity. In the early stages of boutonniere,

the deformity is easily reducible and the Haines-Zancolli

test is negative. In late or fixed deformity, the fibers of the

retinacular ligament are contracted and passive flexion of

the DIP joint is not possible. If the PIP joint cannot be

fully extended, a positive retinacular plus test may be

masked.

Authors’ Comment

The authors of and the commentators [Tubiana et al.

(1996)] on this test emphasize the importance of contrac680 Appendix

ture of the oblique retinacular ligament (ORL). Perhaps it

is the ORL that is the first structure to be contracted, followed by contracture of the palmarly displaced lateral

bands. This test appears to be similar if not identical to the

Boyes test for boutonniere deformity.

References

Haines RW. The extensor apparatus of the finger. J Anat 85:251,

1951.

Tubiana R, Thomine JM, Mackin E. Examination of the hand and

wrist, 2nd ed. St. Louis: Mosby, 1996:220–222.

Zancolli E. Structural and dynamic basis of hand surgery. Philadelphia:

JB Lippincott, 1968:106–107, 121.

HENLE, NERVE OF

Definition

The nerve of Henle is a branch of the ulnar nerve that arises

in the proximal forearm and provides sympathetic nerve

fibers to the ulnar artery and sensory fibers to the distal

forearm and ulnar side of the palm.

Clinical Significance

McCabe and Kleinert (1990) found that this nerve has a

relatively high incidence and provides sympathetic nerve

fibers to the ulnar artery and sensory fibers to the distal

forearm and ulnar side of the palm. They noted similarity between the distal components of this nerve and the

palmar cutaneous branch of the ulnar nerve (PCBUN),

and no separate PCBUNs were found in their dissections.

The findings of McCabe and Kleinert are contrasted to

those of Martin et al. (1996), who studied the cutaneous

innervation of the palm in 25 hands and noted the

PCBUN to be present in 4 of 25 specimens and the nerve

of Henle as a sensory branch to be present in 10 of 25

specimens.

References

Henle J. Handbuch der Systematischen Anatomic den Menschen. Braunschweig, Germany: von Friedrich Vieweg and Sohn, 1868.

Martin CH, Seiler JG III, Lesesne JS. The cutaneous innervation of

the palm: an anatomic study of the ulnar and median nerves. J

Hand Surg 21A:634–638, 1996.

McCabe SJ, Kleinert JM. The nerve of Henle. J Hand Surg [Am]

15:784–788, 1990.

HOFFMANN-TINEL SIGN

Definition

The Hoffmann-Tinel sign is a useful clinical sign to determine the level of nerve injury or recovery based on the presence of injured or regenerating axons.

Technique

This test is performed by percussion of the nerve distal to the

lesion with proximal advancement of the digital percussion

until the lesion is reached or the zone of regeneration identified. The percussion, performed gently with the examiner’s

fingertip, progresses along the course of the nerve until the

end point is identified by paresthesia either localized to the

zone of injury in cases of complete nerve interruption, or distally into the zone of cutaneous innervation. Some clinicians

prefer to percuss from proximal to distal to the site of the

lesion downward until the paresthesia disappears.

Clinical Significance

The paresthesia or “pins and needles” sensation noted with the

digital percussion is caused by the regenerating axons that are

sensitive to percussion, in part because of loss of the myelin

sheath as part of Wallerian degeneration. A positive response

over a long segment of nerve may be due to unequal rates of

growth of various sensory fibers. The sign may be absent in

the first 4 to 6 weeks after nerve suture, and the onset and

progress of the sign may be inversely proportional to the severity of the injury. The sign may be difficult to elicit beneath a

large muscle mass. Steady distal progression of the end point

is a favorable sign in nerve regeneration, but it must be recognized that the sign is qualitative, not quantitative.

Historical Perspective

This sign was described in the same year (1915) by a German physiologist, Paul Hoffmann (1884–1962) and Jules

Tinel (1879–1952), a French neurosurgeon. Hoffmann

published his first paper on the subject in March, 1915 and

Tinel in October, 1915. They served their respective countries on opposing sides of the Front in the First World War.

The references listed here are of more than historical

interest.

Reference

Buck-Gramcko D, Lubahn JD. The Hoffmann-Tinel sign. J Hand

Surg [Br] 18:800–805, 1993.

Hoffmann P. Uber eine Methode, den Erfolg einer Nervennaht zu

Beurteilen. Med Klin 11:359–360, 1915.

Hoffmann P. Weitres uber das Verhalten frisch regenerierter Nerven

und uber die Methode, den Erfolg einer Nervennaht fruhzeitig zu

Beurteilen. Med Klin 11:856–858, 1915.

Tinel J. Le signe du “fourmillement” dans les lesions des nerfs peripheriques. Presse Med 47:388–389, 1915.

HOLSTEIN-LEWIS FRACTURE

Definition

In 1963, Holstein and Lewis described a spiral oblique fracture of the distal humerus in seven patients, in which radial

Anatomic Signs, Syndromes, Tests, and Eponyms 681

nerve paralysis was present in five patients and paresis in

two. They noted radial angulation and overriding at the

fracture site. As the radial nerve courses anteriorly through

the lateral intermuscular septum, it is less mobile and subject to being injured by the movement of the distal fracture

fragment. Because of the high incidence of radial nerve dysfunction, early operative intervention was advised by these

authors.

Clinical Significance and Perspective

A larger and more recent study of this fracture that was

associated with radial nerve palsy revealed that 11 of the

15 who were treated without exploration of the radial

nerve had complete recovery, and in the 4 patients who

were explored, the nerve was in continuity and also

demonstrated complete recovery. Additional perspective

on management of radial nerve palsy is presented in

Chapter 6.

References

Holstein A, Lewis G. Fractures of the humerus with radial nerve

paralysis. J Bone Joint Surg Am 45:1382–1388, 1963.

Szalay EA, Rockwood CA Jr. The Holstein-Lewis fracture revisited.

Orthop Trans 7:516, 1983.

HORNER’S SYNDROME

Definition

1. Miosis (small pupil)

2. Enophthalmos (sinking in of the eyeball)

3. Ptosis (drooping of the upper lid)

Clinical Significance

These physical findings are seen in conjunction with a

brachial plexus injury and indicate avulsion of either or

both the C8 and T1 nerve roots proximal to the dorsal

root ganglion, and indicate that surgical repair is impossible. Horner’s sign may be present immediately after

injury or may be delayed for 3 to 4 days after injury.

Horner’s syndrome also may be seen after stellate ganglion block.

References

Bernard C. Des phénomènes oculo-pupillairas produits par la section

du nerf sympathique cervical; ils sant indépendents des

phénomènes vasculaires coloriques de la tête. C Rend Acad Sci

Paris 55:381–388, 1862.

Horner F. Ueber eine Form von Ptosis. Klin Mbl Augenheilkd

7:193–198, 1869.

Mitchell SW, et al. Gunshot wounds and other injuries of the nerves.

Philadelphia: JB Lippincott, 1864.

HUBER TRANSFER

Definition

The Huber transfer is transfer of the abductor digiti minimi

(ADM) on its neurovascular bundle to restore or augment

opposition of the thumb. The procedure was described by

Huber and Nicholaysen, working independently, in 1921 as

a method to restore opposition after median nerve injury or

poliomyelitis.

Technique

The technique as performed by Manske and McCarroll

(1978) involves detachment of the insertion of the ADM,

freeing it from the adjacent muscle with preservation of the

neurovascular pedicle (by avoiding dissection on the proximal and radial side of the muscle) and preservation of its

origin from the pisiform. The muscle is then passed

through a subcutaneous tunnel and attached to the region

of the metacarpophalangeal joint of the thumb based on the

patient’s deformity.

References

Huber E. Hilfsoperation bei median Uslahmung. Dtsch Z Chir 162:

271–275, 1921.

Manske PR, McCarroll HR Jr. Abductor digiti minimi opponensplasty in congenital radial dysplasia. J Hand Surg[Am] 3:

552–559, 1978.

Nicholaysen J. In: Nordisk kirurgisk forenung fochandlingar, 13th

meeting, Helsingfoes, 1921:118

INTRINSIC TIGHTNESS TEST (FINOCHIETTOBUNNELL TEST)

Definition

This is a two-stage maneuver to test for abnormal tightness

or contracture of the intrinsic muscles and their tendons.

Technique

The test is valid only if passive mobility is retained in the

metacarpophalangeal (MCP) and proximal interphalangeal

(PIP) joints. First, the MCP joint is passively extended and

the degree of passive flexion noted in the PIP joint. The

MCP joint is then passively flexed and the PIP joint again

passively flexed. Normally there is slightly more passive PIP

joint flexion noted when the MCP joint is flexed. A significant increase in PIP joint flexion when the MCP joint is

flexed indicates intrinsic mechanism tightness.

Clinical Significance

Passive extension of the MCP joint places the intrinsic

mechanism on maximum stretch or tightness and, if it is

682 Appendix

contracted, it is difficult if not impossible passively to flex

the PIP joint; however, when the MCP joint is flexed, the

tightness is released and it is possible passively to flex the

PIP joint.

References

Finochietto R. Retraccion de Volkman de los musculos intrinsicos de

los manos. Bol Trab Soc Circ Buenos Aires 4:31, 1920.

Smith RJ. Intrinsic muscles of the fingers: function, dysfunction, and

surgical reconstruction. Instr Course Lect 24:200–219, 1975.

JEANNE’S SIGN

Definition

Jeanne’s sign is hyperextension of the thumb metacarpophalangeal (MCP) joint by 10 to 15 degrees during key

pinch.

Clinical Significance

Paralysis of the adductor pollicis, a stabilizer of the thumb

MCP joint during pinch, is a sign of ulnar nerve palsy.

Reference

Jeanne M. La deformation du pouce dans la paralysie cubitale. Bull

Mem Soc Chir Paris 41:703–719, 1915.

KAPANDJI’S TEST OR SYSTEM

Definition

This is a method of numeric documentation to evaluate

thumb pinch and opposition using landmarks on the

patient’s hand as reference points.

Technique

The examiner notes the ability or inability of the patient to

place the thumb tip to various numbered locations in the

hand as follows:

Position 0: lateral aspect of the index proximal phalanx

Position 1: lateral aspect of the index middle phalanx

Position 2: lateral aspect of the index distal phalanx

Position 3: tip of the index finger

Position 4: tip of middle finger

Position 5: tip of ring finger

Position 6: tip of small finger

Position 7: distal interphalangeal flexion crease of small

finger

Position 8: proximal interphalangeal flexion crease of

small finger

Position 9: metacarpophalangeal flexion crease of small

finger

Position 10: distal palmar crease at base of small finger

Clinical Significance

This test or system provides a numeric, standardized, objective method for noting thumb movement.

References

Kapandji AI. Cotation clinique de l’opposition et de la contreopposition du pouce. Ann Chir Main Memb Super 5:67–73, 1986.

Kapandji AI. Clinical evaluation of the thumb’s opposition. J Hand

Ther 5:102–106, 1992.

LANDSMEER’S LIGAMENT

History and Synonyms

This structure was first described by Weitbrecht in 1742

and was called the retinaculum tendini longi; Landsmeer

called it the oblique band of the retinacular ligament; Haines

called it the link ligament, and Littler the oblique retinacular

ligament. Today it is most commonly known as Landsmeer’s

ligament or the oblique retinacular ligament (ORL).

Definition and Anatomy

These are ligamentous bands on either side of the finger

that arise proximally from the distal aspect of the second

annular pulley and the adjacent distal third of the proximal

phalanx. They continue distally and obliquely across the

proximal interphalangeal (PIP) joint parallel to the lateral

bands and deep to the transverse retinacular ligament, and

then insert variably into the lateral bands at approximately

the level of the PIP joint or into the terminal tendon in the

distal half of the middle phalanx. Milford (1968) noted that

sometimes these fibers could be seen to continue at the lateralmost part of the lateral band as it inserted into the distal phalanx. It is consistently palmar to the PIP and dorsal

to the distal interphalangeal (DIP) joint axis of rotation.

Clinical Significance

The ORL is said to coordinate movement of the interphalangeal joints because extension of the PIP joint places the

ORL under tension and acts as a dynamic tenodesis to aid

the conjoined or terminal tendon in extension of the DIP

joint. Based on this concept, the ORL is placed under tension with DIP joint flexion. Thus, it is stated that the ORL

does not permit easy active or passive flexion of the DIP

joint when the PIP joint is in extension. This may be

demonstrated on one’s finger by noting that active flexion

of the DIP usually is not possible until the PIP joint is

flexed (unless the PIP joint is supported in extension to

allow the powerful flexor digitorum profundus to overcome

Anatomic Signs, Syndromes, Tests, and Eponyms 683

the normal situation). Although the structure and extent,

and thus the functional effect of the ORL may vary from

finger to finger, when thickened and contracted it may play

a role in PIP and DIP joint contracture, as noted in boutonniere deformity.

References

Haines RW. The extensor apparatus of the finger. J Anat 85:251–259,

1951.

Landsmeer JMF. Anatomy of the dorsal aponeurosis of the human

finger and its functional significance. Anat Rec 104:31–44, 1949.

Littler JW. The finger extensor system: some approaches to the correction of its disabilities. Orthop Clin North Am 17:483–492,

1986.

Milford LW. Retaining ligaments of the hand. Philadelphia: WB Saunders, 1968.

Weitbrecht J. Syndesmology (Historia ligamentum corporis humani,

1742). Kaplan EB, transl. Philadelphia: WB Saunders, 1969.

LINBURG-COMSTOCK ANOMALY

Definition

This anomalous intertendinous connection between the

flexor pollicis longus (FPL) and the index finger flexor digitorum profundus (FDP) results in independent loss of

movement or excursion of the FPL. This is clinically manifested by inability to flex the interphalangeal joint of the

thumb without flexion of the index finger distal interphalangeal joint.

Clinical Significance

This intertendinous connection, usually at the wrist or distal forearm level, may interfere with certain specific functions, such as holding and simultaneously cocking the hammer of a pistol. Linburg and Comstock found this anomaly

in 25% cadaver limbs. Although the FPL and FDP of the

index finger usually are independent, phylogenetically both

tendons are derived from a common mesodermal mass.

References

Linburg RM, Comstock BE. Anomalous tendon slips from the flexor

pollicis longus to the flexor digitorum profundus. J Hand

Surg[Am] 4:79–83, 1979.

Takami H, Takahashi S, Ando M. The Linburg Comstock anomaly:

a case report. J Hand Surg [Am] 21:251–252, 1996.

LUMBRICAL PLUS SYNDROME

Definition

Lumbrical plus syndrome is paradoxical extension of the

proximal interphalangeal (PIP) joint that occurs when flexion of the finger is attempted.

Anatomy and Pathomechanics

If the profundus tendon is lacerated in the finger, the proximal end of the tendon migrates proximally because of the

pull of its muscle belly. The lumbrical origin is carried proximally and this increased tension on the lumbrical may produce increased tension in the lateral band and thus extension of the PIP joint.

This condition also may develop after amputations of the

distal phalanx. It may be noted with flexor tendon grafts that

are too long. Wrapping the lumbrical about the repair site of

a lacerated flexor tendon also may be a cause of lumbrical plus

if the lumbrical subsequently contracts or shortens.

Clinical Significance

This condition may be diagnosed if the intrinsic tightness

test is positive after a tendon graft, distal phalanx amputation, or flexor digitorum profundus tendon repair if the

patient demonstrates paradoxical extension of the PIP joint.

Although not a common condition, lumbrical plus may

provide an explanation for paradoxical extension of the PIP

joint in certain conditions.

References

Louis DS, Jebson PJL, Graham TJ. Amputations. In: Green DP,

Hotchkiss RN, Pederson WC, eds. Green’s operative hand surgery,

4th ed. New York: Churchill Livingstone, 1999.

Parkes A. The “lumbrical plus” finger. Hand 2:164–167, 1970.

LUNOTRIQUETRAL BALLOTTEMENT TEST

(MANEUVER)

Definition

This is a test or maneuver to demonstrate a strain or dissociation between the lunate and triquetrum.

Technique

The lunate is stabilized between the thumb and index finger of one hand and then attempts are made to displace the

triquetrum and pisiform dorsally and then palmarly with

the other hand.

Clinical Significance

A positive test demonstrates pain, crepitus, or abnormal

movement and may indicate a partial tear or complete dissociation based on the degree of mobility demonstrated.

References

Kleinman WB, Graham TJ. Distal ulnar injury and dysfunction. In:

684 Appendix

Peimer CA, ed. Surgery of the hand and upper extremity. New York:

McGraw-Hill, 1996:667–709.

Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J

Hand Surg [Am] 9:502–513, 1984.

MANNERFELT HYPERFLEXION SIGN

Definition

In low ulnar nerve palsy, with forceful pinch between the

thumb, index, and long fingers, the metacarpophalangeal

(MCP) joints of the index and long fingers have a tendency to extend while the interphalangeal joints hyperflex.

Clinical Significance

In ulnar nerve palsy, although the first and second lumbricals are not denervated, they are the only barrier against

clawing of the index and long fingers. During forceful

pinch between the thumb and first two fingers, they are

unable completely to replace the function normally performed by the ulnar-innervated interosseous muscles, and

the MCP joints of these two fingers tend to hyperextend

and the interphalangeal joints hyperflex.

References

Mannerfelt L. Studies on the hand in ulnar nerve paralysis: a clinicalexperimental investigation in the normal and anomalous innervation. Acta Orthop Scand Suppl 87:17–34, 91, 1966.

Tubiana R, Thomine JM, Mackin E. Examination of the hand and

wrist, 2nd ed. St. Louis: Mosby, 1996.

MASSE’S SIGN

Definition

Masse’s sign is a loss of the normal transverse metacarpal

arch and loss of elevation of the hypothenar eminence.

Clinical Significance

Paralysis of the opponens digiti minimi and the diminished

range of flexion of the small finger metacarpophalangeal

joint results in flattening of the hand. This appearance of

flattening is increased by the atrophy in the ulnar-innervated hypothenar and interosseous muscles and is a sign of

ulnar nerve palsy.

Reference

Masse L. Contribution a l’etude de l’action des interosseux. J Med

Bord 46:198–200, 1916.

MATEV’S SIGN

Definition

This is an erosion seen on radiography (a depression with

sclerotic margins) of the posterior surface of the medial epicondylar ridge of the humerus due to pressure from a

translocated median nerve that has been entrapped for a

prolonged period after posterior dislocation of the elbow.

Clinical Significance

This finding may represent a late indication for surgical

exploration in median nerve dysfunction after elbow dislocation.

References

Hallet J. Entrapment of the median nerve after dislocation of the

elbow. J Bone Joint Surg [Br] 63:408–412, 1981.

Matev I. A radiologic sign of entrapment of the median nerve in the

elbow joint after posterior dislocation. J Bone Joint Surg [Br] 58:

353–355, 1976.

MONTEGGIA FRACTURE

Definition

This is a fracture of the proximal third of the ulna with

associated anterior dislocation of the radial head. The

mechanism of injury is a fall onto an outstretched hand

while the elbow is partially flexed.

Clinical Significance

The radial head dislocation must not be overlooked. Treatment in adults usually is by internal fixation of the ulna and

closed reduction of the radial head

Reference

Monteggia GB. Istituzioni chirugiche, 2nd ed, vol 5. Milan: Maspero

e Buocher, 1814:129–131.

MUMENTHALER SIGN

Definition

When abduction of the small finger is attempted against

resistance, there is absence of skin dimpling in the proximal portion of the hypothenar eminence in the region of

the palmaris brevis (PB) muscle. Ordinarily, there is wrinkling or dimpling of the skin at the site of insertion of the

PB into the dermis on the ulnar side of the palm with this

maneuver.

Anatomic Signs, Syndromes, Tests, and Eponyms 685

Clinical Significance

Contraction of the ulnar-innervated PB muscle when

abducting the small finger against resistance often results in

dimpling or wrinkling of the skin in the proximal portion

of the hypothenar eminence. If such a finding is absent, it

may indicate ulnar nerve compromise. Although the PB

typically (two-thirds) is innervated by a superficial branch

of the ulnar nerve, it also may be innervated by a branch

from the deep division or from a branch originating near

the superficial and deep branches, and thus may not always

provide specific information about the site of an ulnar nerve

lesion.

References

Mannerfelt L. Studies on the hand in ulnar nerve paralysis: a clinicalexperimental investigation in the normal and anomalous innervation. Acta Orthop Scand Suppl 87:17–34, 91, 1966.

Mumenthaler M. Die Ulnarisparesen. Stuttgart: G Thieme, 1961.

OBLIQUE RETINACULAR LIGAMENT

See Landsmeer’s Ligament.

OLLIER’S PHENOMENON

Definition

This is “dimpling” of the skin in the region of Guyon’s canal

when pressure is applied to the hypothenar eminence due to

compression of the fat in Guyon’s canal. In 1861, Guyon

presented to the Anatomical Society of Paris his account of

the anatomic arrangement of the anterior aspect of the

wrist, which since has come to be known as Guyon’s canal.

This study was apparently prompted by a finding observed

by Ollier and pointed out to Guyon. Ollier’s phenomenon,

according to Ollier, was the appearance of two or three

swellings beneath the skin, like the edge of a distended sac,

when pressure was applied to the hypothenar eminence and

their disappearance when the pressure was released. Guyon

made his dissections to determine whether the swellings

were due to fat or “a condition of the synovial tendon

sheaths.”

Clinical Significance

Guyon’s investigation of Ollier’s phenomenon is a prime

example of the role of anatomy in the advancement of

surgery (see Guyon’s Canal).

References

Denman EE. The anatomy of the space of Guyon. Hand 10:69–76,

1978.

Guyon F. Note sur une disposition anatomique propre a la face

antereriure de la region du poiget et non encore decrite. Bull Soc

Anat Paris 6:184–186, 1861.

PARONA’S SPACE

Definition

This is a non–synovial-lined space on the flexor side of the

wrist located between the flexor tendons and the pronator

quadratus muscle. It is bounded radially by the flexor carpi

radialis and ulnarly by the flexor carpi ulnaris and antebrachial fascia.

Clinical Significance

In 85% of Scheldrup’s (1951) study of 367 hands, there was

a natural connection between the radial and ulnar bursa at

the wrist. Parona’s space, located between the radial and

ulnar bursa, thus has the theoretic potential to act as a conduit between these two structures and produce the so-called

horseshoe abscess.

References

Parona F. Dell’oncotomia negli accessi profundi diffusi dell’avambrachio. Annali Universali di Medicina e Chirurgia, Milano, 1876.

Scheldrup EW. Tendon sheath patterns in the hand: an anatomical

study based on 367 hand dissections. Surg Gynecol Obstet

93:16–22, 1951.

PHALEN’S TEST

Definition

This is a wrist flexion test to aid in the diagnosis of carpal

tunnel syndrome.

Technique

The wrist is maintained in full flexion for 60 seconds, and

the test is considered to be positive when the patient feels

symptoms similar to his or her nocturnal symptoms (paresthesias in the median nerve distribution).

Clinical Significance

The effect of wrist flexion is to increase pressure in the

carpal tunnel. The greater the slowing of nerve conduction,

the more likely Phalen’s test will be positive. However, some

patients with carpal tunnel syndrome have a negative

Phalen’s test, and some normal (asymptomatic) patients

have a positive test.

686 Appendix

References

Bauman TD, Gelberman RH, Mubarak SJ, et al. The acute carpal

tunnel syndrome. Clin Orthop 156:151–156, 1981.

Phalen GS. The carpal tunnel syndrome: seventeen years experience

in diagnosis and treatment of six hundred fifty four hands. J Bone

Joint Surg Am 48:211–228, 1966.

PITRES-TESTUT SIGN

Definition

The transverse diameter of the hand is decreased. Radial or

ulnar abduction of the extended long finger is impossible,

and there is inability to bring the tips of the extended digits together into a cone.

Clinical Significance

Severe atrophy of the ulnar-innervated hand muscles

results in loss of breadth or diameter of the hand. Because

of paralysis of the second and third dorsal interosseous

muscles, the extended long finger cannot be abducted to

either side. In ulnar nerve palsy, there is paralysis of the

adductor pollicis muscle as well as the hypothenar and

interosseous muscles, which, along with the claw deformity of the ring and small fingers, makes it impossible to

form the digits into a cone.

Reference

Pitres A, Testut L. Les nerfs en schemas. Paris: Doin, 1925.

POLLOCK’S SIGN

Definition

This is the inability to flex the distal interphalangeal (DIP)

joint of the small finger.

Clinical Significance

Paralysis of the flexor digitorum profundus (FDP) of the

small finger due to ulnar nerve palsy results in loss of flexion of the DIP joint of this finger and indicates an ulnar

nerve lesion in or proximal to the forearm. Although the

FDP of the ring finger also may be denervated, it may share

some innervation from the median nerve, and thus the sign

probably is more reliable as originally described (i.e., small

finger FDP only).

Reference

Pollock LJ. Supplementary muscle movements in peripheral nerve

lesions. Arch Neurol Psychiatry 2:518–531, 1919.

PRONATOR QUADRATUS SIGN

Definition

A radiolucent plane overlying the palmar aspect of the

pronator quadratus (PQ) was described by MacEwan in

1964 associated with undisplaced fractures of the distal

radius and ulna, septic arthritis of the wrist, or

osteomyelitis of a nearby bone. This radiolucent shadow,

seen on the lateral radiograph of the wrist, may change in

shape or position from its normal thin triangle with its

base distal and in contact with the palmar lip of the

radius to having its base reversed or its shadow displaced

palmarward.

Clinical Significance

Based on a study by Sasaki and Sugioka (1989), the PQ

sign was positive in 85% and 88%, respectively, of fresh

undisplaced fractures of the distal radius and acute

injuries of the distal radioulnar joint. In rheumatoid

arthritis with synovitis of the wrist joint, the shadow may

be blurred at the distal end of the radius. Thus, the PQ

sign may aid in the diagnosis of potentially occult injuries

about the wrist, infection in and about the wrist, and synovitis of the wrist joint.

References

MacEwan DW. Changes due to trauma in the fat plane overlying the

pronator quadratus muscle: a radiologic sign. Radiology 82:

879–886, 1964.

Sasaki Y, Sugioka Y. The pronator quadratus sign: its classification

and diagnostic usefulness for injury and inflammation of the

wrist. J Hand Surg [Br] 14:80–83, 1989.

ROLANDO FRACTURE

Definition

This is a “Y”-shaped, intraarticular fracture of the base of

the thumb metacarpal. Unlike Bennett’s fracture, there is

little tendency for the metacarpal to dislocate.

Clinical Significance

Nondisplaced fractures usually are managed by closed

methods. Displaced fractures may require open reduction

and internal fixation.

Reference

Rolando S. Fracture de la base du premier metacarpien. Presse Med

18:303–304, 1910.

Anatomic Signs, Syndromes, Tests, and Eponyms 687

ROOS TEST [ELEVATED ARMS STRESS TEST

(EAST)]

Definition

This test is said by Roos to be the most reliable test for evaluation of the thoracic outlet compression syndrome,

including neurologic, venous, and arterial types.

Technique

The patient’s arms are placed in the “surrender” position

(arms elevated and elbows flexed to 90 degrees and the arm

externally rotated) for 3 minutes. During this time, the

patient opens and closes the hands every 2 seconds and

describes any symptoms that develop.

Clinical Significance

This position tends to close the costoclavicular space and

tense the neck and shoulder muscles to create the abnormal

compression mechanisms that may compress the brachial

plexus and subclavian vessels. In neurologic compression,

there may be a tingling sensation in the hand and forearm

with an aching sensation that makes the patient want to

lower the arms. In venous compression, the arm may

become cyanotic and the forearm and wrist veins distended.

In arterial compression, the radial pulse may be diminished

or occluded with signs of ischemia, and the arms may fall.

Reference

Roos DB. Thoracic outlet syndrome: update. Am J Surg 154:

568–573, 1987.

SEYMOUR’S FRACTURE

Definition

Seymour’s fracture is an epiphyseal fracture of the base of

the distal phalanx in a child with dorsal dislocation of the

nail plate and disruption of the nail matrix.

Clinical Significance

Physeal fracture of the distal phalanx of the finger as described

by Seymour (1966) is easily diagnosed because of the dislocated nail plate that is dorsal to the proximal nail fold. The

injury by definition results in disruption of the nail matrix;

anatomic reduction of both the nail plate and nail matrix is

required. Toddlers may sustain a Salter type I injury of the distal phalanx without dislocation of the nail plate, which may

be missed initially because of the absence of the dislocated nail

plate. If untreated, this injury may result in derangement of

extensor tendon function, growth deformity of the distal phalanx, and disruption of articular relationships.

References

Seymour N. Juxta-epiphyseal fracture of the terminal phalanx of the

finger. J Bone Joint Surg Br 347–349, 1966.

Waters PM, Benson LS. Dislocation of the distal phalanx epiphysis in

toddlers. J Hand Surg[Am] 18:581–585, 1993.

SKIER’S THUMB

Definition

Acute disruption of the ulnar collateral ligament (UCL) of

the metacarpophalangeal (MCP) joint of the thumb with or

without an avulsion fracture (see also Stener Lesion).

Clinical Significance

Avulsion of the UCL of the thumb MCP joint may occur

from a variety of mechanisms that produce a radial deforming force at the MCP joint of the thumb. This injury often

is seen in snow skiers as a result of pole injury or falls, hence

its name.

Reference

Frykman G, Johansson O. Surgical repair of rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb.

Acta Chir Scand 112:58–64, 1956.

SMITH’S FRACTURE

Definition

This is a fracture of the palmar aspect of the distal radius

with proximal displacement of the fracture fragment and

dorsal displacement of the distal ulna.

Clinical Significance

Smith distinguished this fracture from a carpal dislocation

and accurately described its nature based on the clinical

deformity, the relative ease of reduction followed by recurrence of the deformity after release of traction, the presence

of crepitus with traction, and the palpable and irregular

margin of the radius.

References

Smith RW. A treatise of fractures in the vicinity of joints and on certain

forms of accidental and congenital dislocation. Philadelphia: Lea and

Blanchard, Hodges and Smith, 1847:162.

Smith RW. Fractures in the vicinity of joints and on certain forms of accidental and congenital dislocation. Philadelphia: Lea and Blanchard,

Hodges and Smith, 1850.

688 Appendix

STENER LESION

Definition

In 1962, Stener described complete rupture of the ulnar

collateral ligament (UCL) at the thumb metacarpophalangeal (MCP) joint, with interposition of the adductor

aponeurosis between the distally avulsed UCL and its site of

insertion and associated instability of the MCP joint. This

configuration is easy to understand based on the fact that

the UCL is deep to the adductor aponeurosis and with avulsion is carried proximally, while the leading edge of the

adductor aponeurosis is carried distally by the deforming

force of injury. When the force abates and the proximal

phalanx returns to its normal alignment, the UCL is external rather than deep to the adductor aponeurosis.

Clinical Significance

The recognition of complete (the Stener lesion) versus partial tears of the UCL may aid the surgeon in selection of a

treatment plan based on the surgeon’s personal preference

and experience and the patient’s needs.

Reference

Stener B. Displacement of the ruptured ulnar collateral ligament of

the metacarpophalangeal joint of the thumb: a clinical and

anatomical study. J Bone Joint Surg Br 44:869–879, 1962.

STRUTHERS’ LIGAMENT

Definition

The ligament of Struthers is an anomalous structure that

spans between a supracondylar process on the anteromedial

aspect of the humerus and the medial epicondyle, and thus

creates an arcade that contains the median nerve and

brachial artery.

Clinical Significance

The median nerve may be compressed beneath the ligament

of Struthers with symptoms that may include aching pain

in the region of the elbow and diminished sensibility in the

median nerve distribution in the hand. Weakness of grip

may be noted, and sometimes the supracondylar process

may be palpable (see also Arcades of Struthers). The ligament of Struthers is a component of arcade VIII of the

median nerve/brachial artery type arcades as originally

described by Struthers in 1854.

References

Al-Qattan MM, Husband JB. Median nerve compression by the

supracondylar process: a case report. J Hand Surg [Br] 16:

101–103, 1991.

Smith RV, Fisher RG. Struthers’ ligament: a source of median nerve

compression above the elbow. J Neurosurg 28:778–779, 1973.

Struthers J. On some points in the abnormal anatomy of the arm. Br

Foreign Med Chir Rev 14:170–179, 1854.

Vesley DG, Killian JT. Arcades of Struthers. J Med Assoc State Al

52:33–37, 1983.

STRUTHERS’ ARCADE

Definition

The arcade of Struthers is a fibrous tissue structure in the

arm that occurs 8 cm proximal to the medial epicondyle. It

arises from the medial intermuscular septum, crosses over

the ulnar nerve, and inserts into the fascial elements of the

medial head of the triceps. It is in fact arcade I of the ulnar

nerve type of arcades in the arm as originally described by

Struthers in 1854 (see Arcades of Struthers).

Clinical Significance

The arcade of Struthers may be a factor in compression of

the ulnar nerve in the arm.

References

Al-Qattan MM, Murray KA. The arcade of Struthers: an anatomical

study. J Hand Surg [Br] 16:311–314, 1991.

Struthers J. On some points in the abnormal anatomy of the arm. Br

Foreign Med Chir Rev 14:170–179, 1854.

SUNDERLAND’S SIGN

Definition

This is the inability to rotate, oppose, or supinate the small

finger toward the thumb during attempted opposition of

the thumb to the small finger.

Clinical Significance

This is a sign of ulnar nerve dysfunction due to paralysis of

the ulnar-innervated hypothenar muscles (abductor digiti

minimi, flexor digiti minimi, opponens digiti minimi).

Reference

Sunderland S. The significance of hypothenar elevation in movements

of opposition of the thumb. Aust N Z J Surg 13:155–156, 1944.

TERRY THOMAS SIGN

Definition

This is separation of the proximal pole of the scaphoid and

adjacent lunate as seen on an anteroposterior radiograph of

the wrist.

Anatomic Signs, Syndromes, Tests, and Eponyms 689

Clinical Significance and Historical Note

This separation indicates a rotatory subluxation of the

scaphoid in which the proximal pole of the scaphoid is displaced dorsally, a condition called scapholunate dissociation

(SLD). This is seen on anteroposterior radiographs as a

wide separation between the proximal pole of the scaphoid

and the lunate. Victor Frankel (1959) noted the similarity

between the dental diastema of the British comedian, Terry

Thomas, and the clinical entity of rotatory subluxation of

the scaphoid (SLD). He used Mr. Thomas’ dental diastema

as a useful anthropomorphic sign to be applied to the diagnosis of this wrist condition.

References

Frankel VH. The Terry-Thomas sign. Clin Orthop 129:321–322,

1977.

Thomas T. Filling the gap. Toronto: Clarke Irwin, 1959.

THURSTON HOLLAND’S FRAGMENT

Definition

This is a triangular metaphyseal fragment that accompanies

the epiphysis in a displaced epiphyseal fracture separation.

Clinical Significance

This fragment may be used to assess the accuracy of reduction after Salter type II fractures.

Reference

Holland CT. A radiographical note on injuries to the distal epiphysis

of the radius and ulna. Proc R Soc Med 22:695–700, 1929.

WARTENBERG’S SIGN

Definition

The small finger assumes an abducted posture and there is

inability to adduct the extended small finger to the

extended ring finger.

Clinical Significance

This posture of the small finger is seen in ulnar nerve palsy

and is due to the action of the extensor digiti minimi (EDM),

which is unopposed by the ulnar-innervated third palmar

interosseous. Gonzalez and associates (1995) studied the

extensor tendons to the small finger in 50 specimens and

noted that only 22 of the specimens had either an attachment

of the EDM to the abductor tubercle on the proximal phalanx

(10 specimens) or an unbalanced ulnar slip of the EDM (12

specimens), which would account for Wartenberg’s sign in

ulnar nerve dysfunction. This 44% incidence would explain

why Wartenberg’s sign is not always present even in complete

lacerations of the ulnar nerve.

References

Gonzalez MH, Gray T, Ortinau E, et al. The extensor tendons to the little finger: an anatomic study. J Hand Surg [Am] 20:844–847, 1995.

Wartenberg R. A sign of ulnar palsy. JAMA 112:1688, 1939.

WARTENBERG’S SYNDROME

Definition

Wartenberg in 1932 described an isolated neuritis of the

superficial radial nerve in the distal forearm, which he

called cheiralgia paraesthetica, in five patients. The condition is characterized by persistent pain on the dorsal radial

surface of the distal forearm with radiation into the thumb,

index, and middle fingers. This isolated neuritis is associated with sensitivity to percussion over the radial nerve in

the region of the radial styloid along the dorsal aspect of the

brachioradialis muscle.

Clinical Significance

Isolated neuritis of the superficial branch of the radial nerve

may be associated with hemorrhage in the proximal forearm, tumors of or about the radial nerve, and thrombosis of

the radial recurrent vessels. Neuritis also may be associated

with variety of traumatic or iatrogenic causes, including a

direct blow to the nerve, tight watchbands or jewelry, handcuffs, or injury due to laceration or compression from

retraction during surgery.

References

Ehrlich W, Dellon AL, Mackinnon SE. Chieralgia paresthetica

(entrapment of the radial sensory nerve). J Hand Surg [Am]

11:196–199, 1986 [This article contains a translation in condensed form of Wartenberg’s original German text].

Wartenberg R. Cheiralgia paraesthetica (Isolierte Neuritis des Ramus

Superficialis Nervi Radialis). Z Ges Neurol Psychiatr 141:

145–155, 1932.

WATSON’S TEST (SCAPHOID SHIFT TEST)

Definition

This is a maneuver to evaluate the scapholunate joint of the

wrist.

Technique

Firm pressure is applied by the examiner’s thumb to the palmar side of the distal pole of the scaphoid while the other

hand moves the wrist from ulnar to radial deviation.

690 Appendix

Clinical Significance

In normal wrists, the scaphoid cannot flex because of the

pressure from the examiner’s thumb. This may produce

pain on the dorsal aspect of the wrist because of synovial

irritation at the scapholunate junction. A positive test is

seen in patients with a scapholunate tear or in hypermobile

(lax) joints. In scapholunate tear, the proximal pole of the

scaphoid migrates out of the scaphoid fossa, and when pressure on the scaphoid is removed, it snaps back into position.

Reference

Watson HK, Ashmead D IV, Makhlouf MV. Examination of the

scaphoid. J Hand Surg [Am] 13:657–660, 1988.

WRIGHT’S TEST

Definition

This is an arm hyperabduction maneuver for diagnosis of

thoracic outlet compression syndrome.

Technique

The arm is externally rotated and abducted 180 degrees

with the elbow flexed. The patient is asked to inhale deeply

and the radial pulse is palpated. Diminution of the radial

pulse is considered to be a positive test, along with numbness and tingling in the hand and weakness in the arms.

Clinical Significance

During hyperabduction, the costoclavicular space may be

narrowed by the upward and posterior movement of the

clavicular space. Neurovascular compression may occur

beneath a taut pectoralis minor muscle near its insertion.

References

Atasoy E. Thoracic outlet compression syndrome. Orthop Clin

North Am 27:265–303, 1996.

Wright IS. The neurovascular syndrome produced by hyperabduction

of the arms: the immediate changes produced in 15 normal controls, and the effect on some persons of prolonged hyperabduction

of the arms, as in sleeping, and certain occupations. Am Heart J

29:1, 1945.

YERGASON’S TEST (SUPINATION SIGN)

Definition

This is a test for or a sign of tenosynovitis of the long head

of the biceps tendon.

Technique

The elbow is flexed to 90 degrees and the examiner holds

the forearm in pronation and asks the patient actively to

supinate the forearm against resistance. A positive test is

manifested by pain localized to the bicipital groove.

Clinical Significance

The biceps is the main supinator of the forearm, and its

action against resistance in the presence of tenosynovitis of

its long head results in localized pain in the bicipital groove.

Reference

Yergason RM. Supination sign. J Bone Joint Surg 13:160, 1931.

Anatomic Signs, Syndromes, Tests, and Eponyms 691

SUBJECT INDEX

A

Abductor digiti minimi muscle, 155–156,

182t, 583, 583f

accessory, 214

transfer of, 682

Abductor indicis muscle, 161–162, 587

Abductor pollicis brevis muscle, 149–152,

182t, 582–583, 582f

actions and biomechanics of, 150, 151f

anomalies and variations of, 152

clinical correlations of, 152

gross anatomy of, 149–150

innervation of, 211

Abductor pollicis longus bursitis

(intersection syndrome), 133, 134,

146–148, 480, 482f, 483

Abductor pollicis longus muscle, 145–147,

181t, 465f, 466

innervation of, 427, 428t

in intersection syndrome, 480, 482f,

483

as landmark, 461, 462f

Abductor pollicis longus tendon, de

Quervain’s tenosynovitis of,

476–477, 477f, 478f

Abductor pollicis tertius muscle, 146

Accessories ad flexoram digiti minimi

muscle, 119

Accessory bone(s). See specific bones and

accessory bone names

Accessory muscle(s). See specific muscles

Acromial branch, of thoracoacromial artery,

241

Acromial portion, of clavicle, 4, 4f, 5f

Acromioclavicular joint, 5–6, 6f, 17

separation of, 7–8

Acromioclavicular ligament, 6, 6f

Acromion

as landmark, 315, 317f

ossification center for, 8–9, 9f

osteology of, 10, 10f–14f, 15t

Adductor compartment, compartment

syndrome of, 634, 634f, 635f

Adductor pollicis muscle, 154–155, 182t,

582–583, 582f

Adductor (deep palmar radial) space, 604

Adson’s maneuver (test), 669

AIN. See Interosseous nerve(s), anterior

Alar thoracic artery, 243

Allen test, 260, 669–670

Ames classification, of thumb arterial

patterns, 563–564, 563f

Anastomosis. See also specific arches

brachial artery, 247

Froment-Rauber, 219

Martin-Gruber. See Martin-Gruber

anastomosis

Riche-Cannieu, 163, 197–198, 211,

636–637, 636f, 637f, 673–674

Anatomic neck, of humerus, 18, 20, 20f,

21f, 25

Anatomic snuffbox, 148–149, 262–263,

486–487, 487f, 642

Anconeus epitrochlearis muscle, 124, 208,

405, 456

Anconeus muscle, 105–106, 180t, 461,

463f, 464f, 465

Anconeus sextus muscle, 106

Andre-Thomas sign, 670, 676

Aneurysm

of radial artery, 269

of ulnar artery, 260

Angle(s)

of attack, in intrinsic muscles, 588f, 589

Baumann’s, 386, 387f

carrying, of elbow, 365–366

of scapula, 8–9, 9f–14f, 16–17

Annular ligament, of radius, 31f, 32f,

370–371, 371f, 373f

Annular pulleys, 600–602, 600f

Antebrachial cutaneous nerve

lateral, 321, 322f, 323f

anomalies and variations of, 223

in antecubital fossa, 424f

clinical correlations of, 223

course of, 222–223

of forearm, 414–416, 415f

as nerve graft, 444, 445f

surgical exposures for, 444, 445f

medial, 224–225, 321, 322f–325f, 329f,

413–414, 415f

anomalies and variations of, 204–205,

223, 321

anterior branch of, 223

in brachial plexus, 304f, 306

clinical correlations of, 223–224

course of, 200, 201f–203f, 204, 223

as nerve graft, 321

origin of, 223

posterior (ulnar) branch of, 223

posterior, 323f

Antebrachial vein, median, 271, 272, 273f,

276, 320f, 413, 414f

Antecubital fossa

arteries in, 423–424, 424f, 425f

contents of, 423

landmarks of, 422, 424f

median nerve in, 431, 432f

muscles of, 422–423, 424f

surgical exposures for, 435–437, 435f, 436f

zones of, 422–423, 424f

Anterior interosseous nerve. See Interosseous

nerve(s), anterior

Anterior interosseous nerve syndrome, 127,

129, 193, 446–449

compression sites in, 447, 448f, 449

differential diagnosis of, 194, 447

pathogenesis of, 449

treatment of, 449

Anterior ligament, of elbow, 370–371

Anterior oblique ligaments, of thumb,

538–540, 538t, 539f

Apical (subclavicular) group of axillary

lymph nodes, 280f, 281

APL muscle. See Abductor pollicis longus

muscle

Aponeurosis

dorsal, 590–592, 590f, 591f

extensor, 135–136, 136f, 137f

Page numbers followed by “f” indicate an illustration; page numbers followed by “t” indicate a table.

Arcade(s), 356–362

in brachial artery anastomoses, 247

of Frohse, 144–145, 217, 429–430, 429f,

670

radial nerve branches above, 429, 430f

radial nerve compression by, 478, 479f

of nail unit, 655, 655f

of Struthers, 204, 205, 356–362,

670–671, 689

clinically significant, 356, 359f–361f,

361–362, 670–671

I to IV, 357f–358f, 360t, 671

ulnar nerve and, 362f, 362, 671,

389–390, 389f–391f

VII, 356, 361, 361f, 670

VIII, 360f, 360t, 361–362, 361f, 670

V to VII, 359f, 360t

venous, metacarpal, 644, 644f, 645f

Arches

of hand, 536, 536f

vascular. See specific arches

Arcuate artery, of humeral head, 332, 333f

Arm, 315–364. See also Forearm; specific

structures

anatomic relationships of, 320–341

brachial artery. See Brachial artery

cutaneous nerves, 321, 322f–325f, 325

humeral arterial supply, 332, 333f, 334

intermuscular septa, 327, 329f–331f,

394–395, 394f–396f

median nerve. See Median nerve, in

axilla and arm

muscles, 325–327, 326f, 328f

musculocutaneous nerve. See

Musculocutaneous nerve

radial nerve. See Radial nerve

veins, 320, 320f

anomalies and variations of, 356,

357f–361f, 360t, 361–363

anteromedial, landmarks of, 315, 318f

arcades of, anomalies and variations of,

356, 357f–361f, 360t, 361–362

clinical correlations of, 355–356

descriptive anatomy of, 315–318,

316f–319f

landmarks of, 315, 316f–318f

lateral, landmarks of, 315, 316f

medial cutaneous nerve of (medial

brachial cutaneous nerve), 223–224

median nerve in. See Median nerve, in

axilla and arm

muscles of, 325–327, 326f, 328f. See also

specific muscles

nerves of. See also specific nerves

cutaneous, 321, 322f–325f, 325

neurovascular structures of, 327–341. See

also specific arteries and nerves

posterior, landmarks of, 315, 317f

skeletal anatomy of, 315, 317–318, 319f.

See also Humerus

surgical exposures for, 341–353

anterior approach to humerus, 341,

342f–344f

anterolateral approach to distal

humerus, 341, 343, 345, 345f,

346f

medial approach, 346, 347, 347f–349f,

351

posterior approach, 351–353,

350f–353f

proximal posterior approach to

humerus, 353, 354f, 355f

ulnar nerve in. See Ulnar nerve, in axilla

and arm

vasculature of. See specific arteries and

veins

veins of, 320, 320f. See also Brachial

veins; Cephalic vein

Arteria antebrachialis superficialis dorsalis,

268

Arteria radialis superficialis, 268

Arteriovenous gradient theory, of

compartment syndrome, 449

Artery(ies)

alar thoracic, 243

of antecubital fossa, 423–424, 424f,

425f

arcuate, of humeral head, 332, 333f

axillary. See Axillary artery

brachial. See Brachial artery

carpal, recurrent, 238f, 267f

cervical, 301, 302f

circumflex subscapular, 238f, 239f, 242

digital. See Digital artery(ies)

of digital web spaces, 560

of elbow, 368, 368f–369f, 370, 370t

extensor compartment, 515, 516f

of fingers, 560–568, 561f, 562t, 563f,

565f, 567f. See also specific arteries

of forearm, 197, 431, 434f

of hand, 549–568

humeral circumflex, 238f, 239f,

242–244, 331f, 332, 333f

intercarpal, 45–46, 46f–49f, 511

intercompartmental, of wrist, 514–516,

516f, 517f

interosseous. See Interosseous artery(ies)

lumen diameters of

digital, 562, 562t

in hand, 256t, 559, 559t

main trunks of, 238f

median. See Median artery

metacarpal. See Metacarpal artery(ies)

of nail unit, 655–656, 655f

nutrient, 246, 332, 333f

palmar, 261, 509, 509f

of phalanges, l, 655–656, 655f

pollicis, 253f, 255f, 265f, 507f, 508f,

551f

princeps pollicis, 266, 267f, 269, 562

radial. See Radial artery

radial index, 259, 266–267, 562

radial recurrent. See Radial recurrent

artery

subclavian, 299f, 300f, 301f, 302f

subradicular, 301

subscapular, 238f, 239f, 241–243

supraretinacular, 514–515, 516f

suprascapular, 302f, 305

thoracic, 238f, 239f, 240–241, 243

thoracoacromial, 238f, 239f, 241

thoracodorsal, 238f, 239f, 242

thoracoepigastric, 243

of thumb, 562–568, 563f, 565f, 567f

ullnar collateral. See Ulnar collateral

arteries

ulnar. See Ulnar artery

ulnar recurrent. See Ulnar recurrent

artery(ies)

ulnodorsal digital, 567

ulnopalmar digital, 566

vs. veins, 270

of wrist. See Wrist, vascular anatomy of

Arthritis, of radioulnar joint, 36

Arthroplasty, of metacarpophalangeal joint,

656, 657f

Articular branches, of ulnar nerve, 204

Articular disc, of sternoclavicular joint, 6–7,

6f

Articularis cubiti, 104

Articular nerves, 573

Avascular necrosis

of carpus, 513–514

of lunate, 514

of scaphoid, 49, 514

Axilla

median nerve in. See Median nerve, in

axilla and arm

musculocutaneous nerve in, 222

ulnar nerve in. See Ulnar nerve, in axilla

and arm

Axillary artery, 237–244, 305

anomalies and variations of, 243

anterior humeral circumflex branch of,

238f, 239f, 242, 243

branches of, 238f, 239f, 240t, 240–243

circumflex scapular branch of, 238f, 239f,

242

clinical correlations of, 243–244

course of, 238–240, 238f, 239f

first (proximal) part of, 237, 238f, 239f,

240t

gross anatomy of, 237–240, 238f, 239f,

240t

high division of, 243, 244

injury of, 244

lateral thoracic artery branch of, 238f,

239f, 241, 243

posterior humeral circumflex branch of,

238f, 239f, 242–243

696 Subject Index

second (posterior) part of, 238f,

239–240, 239f, 240t

subscapular branch of, 238f, 239f,

241–243

superior thoracic artery branch of, 238f,

239f, 240–241

third (distal) part of, 238f, 239f, 240,

240t

thoracoacromial artery branch of, 238f,

239f, 241

thoracodorsal branch of, 238f, 239f, 242

Axillary lymph nodes, 279f, 280–281, 280f

Axillary nerve, 305f

anomalies and variations of, 314

in brachial plexus, 306

compression of, 244

in deltoid muscle innervation, 92–93

injury of, 310–311, 311f

surgical exposure for, 310–311

Axillary vein, 275f, 276, 300f

Axis of rotation, of elbow, 374, 374f

B

Backfire fracture, 41, 675

Bado classification, of ulnar fractures, 35

Bankart lesion, 26

Barton’s fracture, 41, 671

reverse, 671

Basal metacarpal arch, 48f, 255f, 265–266,

265f

Baseball (mallet) finger, 652, 653f, 658

Basilic vein, 272, 271f–275f, 274, 320,

320f, 324f

absence of, 276

in axilla and arm, 329f

in forearm, 413, 414f

median, 276

venous arches connected to, 644, 645f

Baumann’s angle, 386, 387f

Beak ligament, of thumb, 540

Bennett’s fracture, 671–672

Berrettini, palmar ulnar-median

communicating branch of, 198, 199

Biceps brachii muscle, 98–101, 99f, 180t,

325, 326f

accessory humeral head of, 362

groove of, as landmark, 315, 316f, 318f

innervation of, 336, 338f

as landmark, 315, 316f, 318f

Biceps brachii tendon

in antecubital fossa, 424f

as landmark, 408, 408f

repair of, 451, 452f

rupture of, at distal insertion, 451, 452f

Bicipital groove, 20, 21f, 23

Bipartite hamulus, 529

Bipartite scaphoid, 44, 50, 529

Bone(s). See Skeletal system; specific bones

Bone grafts, vascularized

radial artery in, 269

for scaphoid nonunion, 517

Boutonniere deformity, 652, 653f, 658–660

Boyes test for, 672

definition of, 658

diagnosis of, 658–659, 659f

Elson test for, 677

Haines-Zancolli test for, 680–681

pathomechanics of, 660

physical findings in, 658

vs. pseudoboutonniere deformity, 660

treatment of, 660

Bouvier’s sign, 672

Bowers approach, to distal radioulnar joint,

517–519, 518f, 519f

Bowler’s thumb, 672

Boyes test, 672

Brachial artery, 244–248, 324f, 327–328,

329f–331f

agenesis of, 248

anastomoses of, 247

anomalies and variations of, 247–248,

362–363

in antecubital fossa, 424f, 425f

in arcade of Struthers, 356, 357f–361f,

360t, 361–362

branches of, 238f, 239f, 245–247, 245f,

240t, 331f

clinical correlations of, 248

in collateral circulation, 248

compression of, 248

in arcade of Struthers, 361–362, 361f

course of, 239f

deep (profunda), 238f, 239f, 245–246,

245f, 331f

accessory arteries from, 332, 333f

in forearm, 434f

gross anatomy of, 244, 245f

high division of, 247, 363

low division of, 363

median nerve near, 340–341, 340f

muscular branches of, 247

protection of, in elbow surgery, 379–380,

381f

superficial, 362–363

surgical exposures for, 346–347,

347f–349f, 351

Brachial cutaneous nerve(s), 202f–203f

intercostal, 323f

lateral, 323f

medial, 223–224, 321, 322f, 325, 329f,

415f

in brachial plexus, 304f, 306

Brachialis muscle, 101–103, 180t, 325–326,

326f, 327f

anomalies and variations of, 362

in antecubital fossa, 424f

capsularis, 103

innervation of, 336, 338f, 340

as landmark, 316f

Brachial lymph vessels, 278

Brachial plexus, 186f, 297–314

anatomic relationships of, 297, 300–306

branches, 301f, 303f, 304f, 306

cords, 300f, 301f, 303f–305f,

305–306, 309, 314

divisions, 301f, 305, 305f

roots, 300–301, 301f–303f, 303–304,

308f

trunks, 301f, 303f–305f, 304–305,

308f

anomalies and variations of, 185–186,

312, 313f, 314

clavicle relationship to, 7

clinical correlations of, 310–312, 311f

cords of, 300f, 301f, 303f–305f,

305–306, 309, 314

descriptive anatomy of, 297, 298f, 299f

divisions of, 301f, 305, 305f

infraclavicular portion of

anatomy of, 311f

surgical exposures for, 308–310, 308f

injuries of, 303, 310–312, 311f

Horner’s syndrome in, 682

medial brachial cutaneous nerve origin in,

223

median nerve origin in, 185, 186f

musculocutaneous nerve origin in, 222

nerves arising from, 302f

paralysis of, 101, 677

postfixed, 297, 312

prefixed, 297, 312

radial nerve origin in, 214

Randy Travis Drinks Cold Beer

mnemonic for, 297

rootlets of, 300

injury of, 308f

roots of, 300–301, 301f–303f, 303–304,

308f

supraclavicular portion of, 302f,

306–308, 306f

suprascapular portion of, 302f

surgical exposures for, 298f, 299f,

306–310

infraclavicular, 308–310, 308f

limited cosmetic incision in, 308

supraclavicular, 306–308, 306f

trunks of, 301f, 303f–305f, 304–305,

308f

ulnar nerve origin in, 200, 201f, 204

vascular structures associated with, 302f,

303

Brachial veins, 274f, 275f, 276

Brachiofascialis muscle of Wood, 103

Brachioradialis brevis muscle, 109, 455

Brachioradialis muscle (supinator longus

muscle), 106–110, 416, 417f

actions and biomechanics of, 108–109

anomalies and variations of, 109–110,

109f, 455

clinical implications of, 110

Subject Index 697

as donor muscle, 110

gross anatomy of, 106–108

innervation of, 428t

as landmark, 316f, 318f

in “mobile wad of three,” 408, 408f, 422,

422f, 461, 462f

Brewerton view, in radiography, 672–673

Bunnell’s “O” test, 673

Bunnell’s “scrape” test, 673

Bunnell’s test, 594, 594f

Bursa, of flexor tendon sheath, 602–603,

603f

Bursitis, abductor pollicis longus

(intersection syndrome), 133, 134,

146–148, 480, 482f, 483

C

Calcification, heterotopic, of elbow, 405

Camper’s chiasma, 121, 607f, 608, 608f

Cannieu-Riche anastomosis, 163, 197–198,

211, 636–637, 636f, 637f, 673–674

Capitate, 41f, 42f, 57–59, 491f

accessory bones of, 57, 59

anomalies and variations of, 58

clinical correlations of, 59

derivation and terminology of, 57

joints associated with, 58

ligaments of, 493–494

muscle origins and insertions of, 59

ossification centers of, 43f, 57

osteology of, 57–58, 58f, 493

vascularity of, 59, 494, 513

Capitohamate ligament, 493, 494, 501f,

503

Capitulum, 21f, 23f, 24, 319f, 366, 367f

ossification centers for, 18, 19f

osteochondrosis of, 27

radiography of, 386–387, 386f, 387f

Capsularis brachialis muscle, 103

Capsular ligaments, dorsal, 500, 500f

Capsule

dorsoradial, injury of, 627

of elbow, 31f–32f, 370

surgical exposure of, 374, 384f, 385,

385f

of radioulnar joint, distal, 498

of sternoclavicular joint, 6–7

Carotid (Chassaignac’s) tubercle, 674

Carpal arches

dorsal, 549–550, 551f, 552f

palmar, 516, 517f

Carpal artery, recurrent, 238f, 267f

Carpal bones, 41–42, 41f–43f, 44t,

490–494, 491f. See also specific bones

accessory, 42, 43f, 44t

arrangement of, 41–42

coalitions of, 42, 43f, 54, 528–529

distal row of, 493–494

joints of, 495

ligaments of, 501–503

joints of, 41–42, 494–495

ossification centers of, 42, 43f

proximal row of, 490, 492

joints of, 494–495

ligaments of, 501f, 502

Carpal ligaments

palmar, 209

transverse, 493, 523f–524f, 595

flexor retinaculum and, 503–504

thenar nerve relationship to, 573–574

Carpal tunnel. See also Carpal tunnel

syndrome

bifid median nerves in, 199

boundaries of, 504, 504f

clinical significance of, 504

as compartment, 504

contents of, 504

median nerve in, variations of, 196–197,

196t

surgical exposures for, 522, 523f–524f

thenar nerve branching and, 574, 574t

Carpal tunnel syndrome

anatomic aspects of, 198–200

compression sites in, 504

flexor digitorum superficialis involvement

in, 122

persistent median artery in, 261

Phalen’s test for, 686–687

surgical treatment of, 522, 523f–524f

Carpometacarpal boss, 661

Carpometacarpal joint(s), 536–540

fourth, anomalies and variations of, 527

index finger, 540

ligaments of, 494

dorsal, 493

finger, 540

thumb, 536–540, 537f, 538t, 539f

long finger, 540

ring finger, 540

small finger, 540

thumb, 536–540, 537f, 538t, 539f

Carrying angle, of elbow, 365–366

Central band, of interosseus membrane,

410–412, 411f

Central bands and slips, of extensor

aponeurosis, 590–592, 590f–592f

Central cord, in Dupuytren’s contracture,

621f

Central group of axillary lymph nodes,

280f, 281

Central palmar compartment, compartment

syndrome of, 634–635, 634f, 635f

Central palmar space, 604, 606f

Cephalic vein, 271, 271f–275f, 300f, 320,

320f

absence of, 276

accessory, 272, 273f

in forearm, 413, 414f

median, 276

venous arches connected to, 644, 645f

Cervical arteries, 301, 302f

Cervical artery, 301

Chassaignac’s tubercle, 674

Chauffeur’s fractures, 41, 675

Check-rein ligaments, of interphalangeal

joints, 546, 546f–547f

Cherry pitter’s thumb, 672, 674

Chieralgia paraesthetica (Wartenberg’s

syndrome), 690

Chondromalacia, of hamate, 57

Circumflex scapular vein, 275f, 276

Circumflex subscapular artery, 238f, 239f,

242

Clavicle, 3–8

absence of, 8

acromial portion of, 4, 4f, 5f

acromion process of

as landmark, 315

ossification center for, 8–9, 9f

osteology of, 10, 10f–14f, 15t

brachial plexus relationship with, 7

clinical correlations of, 7–8

derivation and terminology of, 3

dysostosis of, 8

fractures of, 7

gender differences in, 4

joints associated with, 5–7, 6f

lateral third of, 4–5, 4f, 5f

medial two thirds of, 5

muscle origins and insertions of, 4f, 7

ossification centers of, 3, 4f

osteology of, 3–5, 4f, 5f

osteolysis of, 8

sternal portion of, 5

sternoclavicular, 6–7, 6f

Clavicular branch, of thoracoacromial

artery, 241

Claw deformity

in intrinsic muscle dysfunction, 593,

593f

pseudoulnar, 221

Cleidocranial dysostosis, 8

Cleland’s ligaments, 596f–597f, 598–599,

599f, 674

Coalitions, of carpal bones, 42, 43f, 54,

528–529

Coleman and Anson classification

of deep palmar arch, 552, 554f

of dorsal carpal arch, 549–550, 552f

of superficial palmar arch, 557, 558f,

559, 559f

Collagen, in interosseous membrane,

410–411

Collateral artery, middle, 239f, 253f

of profunda brachial artery, 238f, 245f,

246

Collateral circulation, brachial artery in,

248

698 Subject Index

Brachioradialis muscle (supinator longus

muscle) (contd.)

Collateral ligaments

of fingers, 543f–544f, 545

injuries of, 625–627, 625f

of interphalangeal joints, 546–547, 547f,

548f

lateral

injuries of, 400

insufficiency of, 400–402, 402f,

403f

medial, 371–372, 371f–374f, 374

injuries of, 399–400, 399f

insufficiency of, 400, 401f

radial, 372–374, 373f, 374f

of fingers, 544f

injuries of, 626–627

protection of, in elbow surgery, 378

of thumb, 541–542, 542f

injuries of, 625–627

ulnar. See Ulnar collateral ligament

Colles’ fractures, 36, 40–41, 675

reverse (Smith’s), 41

Commissural cords, in Dupuytren’s

contracture, 622, 623f

Commissural ligaments, proximal and

distal, 595, 596f

Communicating branch

of Berrettini, 198, 199

of ulnar nerve, 201f, 571f, 579–580,

580f, 571f

Communicating veins, oblique, 644f, 646

Compartment syndrome

of forearm, 449–451

anatomy of, 450–451, 450f

etiology of, 449

flexor digitorum superficialis

compression in, 122

important factors in, 450

muscle infarction in, 449–450

pathophysiology of, 449

pronator quadratus involvement in,

130

treatment of, 451, 451f

wick catheter in, 450

of hand, 633–636

adductor, 634, 634f, 635f

central palmar, 634–635, 634f, 635f

hypothenar, 633–634, 634f, 635f

interosseous, 634f, 635, 635f

lumbrical, 634–635, 634f, 635f

thenar, 633, 634f, 635f

treatment of, 635–636, 635f

Condylar branches, of digital arteries,

560–561, 561f

Conoid ligament, 6, 6f, 10f

Conoid tubercle, 4–5, 5f

Contracture

Dupuytren’s, 619–622, 620f, 621f, 622t,

623f, 676

of elbow, 403–405, 404f

of intrinsic muscles, 594–595, 594f

of proximal interphalangeal joint,

632–633, 633f

Volkmann’s, 449

Coracobrachialis inferior muscle, 362

Coracobrachialis longus muscle, 362

Coracobrachialis minor muscle, 97

Coracobrachialis muscle, 96–98, 180t, 326,

326f, 327f

anomalies and variations of, 362

inferior (coracobrachialis longus), 97

innervation of, 338f

Coracoclavicular ligament, 6, 6f

Coracoid process

as landmark, 17–18, 315, 318f

muscle origins and insertions of, 96, 98

ossification center for, 8–9, 9f

osteology of, 10, 10f–14f, 15t

Cords

of brachial plexus, 300f, 301f, 303f–305f,

305–306, 309, 314

in Dupuytren’s contracture, 619–620,

621f, 622t, 623f

Coronoid fossa, of humerus, 21f, 24

Coronoid process, of ulna, 29–30, 29f, 31f,

367, 367f, 409f, 410

fractures of, 35

muscle attachments of, 34

surgical exposures for, 379–380, 380f,

381f

Costoclavicular ligament, 6f, 7

Creases, flexion, 532–534, 533f, 534f

of fingers, 488f, 533, 533f, 534f

of wrist, 488f, 489, 489f

Crossed fingers test, 674–675

Cross-over tendinitis (intersection

syndrome), 133, 134, 146–148,

480, 482f, 483

Cruciform fibers, of digital flexor sheath,

600–601, 600f

Crutch palsy, 355

Cubital tunnel. See also Cubital tunnel

syndrome

anatomy of, 205–206

shape of, 391, 392f

ulnar nerve in, 205–206

Cubital tunnel syndrome, 106, 208–209,

208t, 388–398

clinical findings in, 388

compression sites in, 389–392,

389f–392f

definition of, 388

gender differences in, 389

pathomechanics of, 388–389

surgical treatment of, 392–395,

393f–397f

Cubital vein, median, 272, 273f, 274f, 276,

320f, 413, 414f

Cuneiform. See Triquetrum

Cutaneous nerve(s), 321, 322f–325f, 325.

See also Musculocutaneous nerve

antebrachial

lateral, 222–223

medial, 200, 201f–203f, 204–205

brachial, 202f–203f

medial, 223–224

courses of, 201f–203f

dorsal branch of, of ulnar nerve, 201f,

206–209, 212

of forearm, 413–414, 415f

of hand, palmar, 568–570, 569f

medial, 306

palmar branch of

of median nerve, 189, 191, 194, 195,

202f

of ulnar nerve, 201f, 206, 212

protection of, in elbow surgery, 379

D

Deep anterior oblique ligament, of thumb,

538, 538t, 539f, 540

Deep arches, palmar. See Palmar arches,

deep

Deep distal hiatus, of Guyon’s canal, 577

Deep motor branch, of ulnar nerve, 201f,

210–212

neural loop of, 637–638, 638f

variations in, 212

Deep palmar branch, of ulnar artery, 254

Deltoid ascending branch, of profunda

brachial artery, 246

Deltoid branch, of thoracoacromial artery,

241

Deltoid muscle, 92–96

anomalies and variations of, 94, 96

atrophy of, 96

clinical correlations of, 96

derivation and terminology of, 92

gross anatomy of, 92–93, 93f–95f

innervation of, 92–93

insertion of, 93, 93f–95f

as landmark, 317f, 318f

origin of, 92, 93f–95f

paralysis of, 96

vascular supply of, 92

Deltoid tuberosity, 23, 317, 319f

Deltopectoral fascia, in median nerve

compression, 188

Deltopectoral groove, 315, 318f, 320, 320f

Deltopectoral lymph nodes, 278, 279f

de Quervain’s fracture, 675–676

de Quervain’s tenosynovitis, 146, 476–477,

477f, 478f, 675

extensor pollicis brevis in, 148

Finkelstein’s test for, 476–477, 477f,

678–679

Dermatomes, 226

Digit(s). See Finger(s)

Digital artery(ies), 560–562, 561f

common, lesions of, 261

condylar branches of, 560–561, 561f

Subject Index 699

digital nerve locations and, 261–262

distal transverse, 609, 610f

dorsal, 560–562, 561f

skin branches of, 560–561, 561f

of thumb, 567

interphalangeal transverse, 609, 610f

metaphyseal branches of, 560–561, 561f

in nail unit, 655–656, 655f

palmar, 560

common, 238f, 249f, 258–260, 267f,

655–656, 655f

proper, 238f, 249f, 258–259, 267f,

508f

of thumb, 566

proper, 238f, 249f, 258–259, 267f,

508f

lesions of, 261

proximal transverse, 609, 610f

radiodorsal, 567–568

radiopalmar, 566

third common, 568

transverse palmar arches arising from,

560–561, 561f

ulnodorsal, 567

ulnopalmar, 566

Digital cord, in Dupuytren’s contracture,

621f, 622

Digital creases, 488f, 533, 533f, 534f

Digital fascia, 598–599, 598f, 599f

Digital flexor sheaths, 600–602, 600f

Digital lymph vessels, 277

Digital nerves, 572–573, 572f

compression of, cherry pitter’s thumb in,

672, 674

digital artery digital locations and,

261–262

of index finger, 573

in nail unit innervation, 656

palmar, common, course of, 195

proper, 195–196, 572–573, 572f

radial, surgical risk to, 612f, 613

skin reference lines for, 535f

of thumb, 571f–572f, 573

neuroma of, 672

ulnar, surgical risk to, 612f, 613

Digital plexus (lymphatic vessels), 277

Digital sheet, lateral, 620f, 622

Digital veins, 270–271, 271f, 272f, 275

dorsal, 644, 644f, 645f

palmar, 644–646, 644f

valves in, 646

Digital web spaces, arterial supply of, 560

DIP. See Interphalangeal joint(s), distal

Dislocation(s), 627–632

of elbow, 386–387, 386f, 398–399

of extensor pollicis longus tendon, 149

of fingers

ring, 76

small, 78

of interphalangeal joint, proximal,

631–632, 631f

of metacarpophalangeal joint

index finger, 628–630, 629f, 630f

thumb, 627–628, 628f

of shoulder, 25, 26

of ulnar nerve, snapping elbow in, 398

of ulnohumeral joint, 398–399

Distal wrist crease, 488f, 489, 489f, 533f,

534, 534f

Divisions, of brachial plexus, 301f, 305,

305f

Dorsal aponeurosis, 590–592, 590f, 591f

Dorsal branch, of ulnar nerve, 323f

Dorsal carpal branch

of radial artery, 264, 265f

of ulnar artery, 238f, 249f, 254, 249f,

265f, 551f

Dorsal compartments, 145–146

extensor pollicis brevis in, 147

Dorsal cutaneous branch, of ulnar nerve,

201f, 206–208, 415f

absence of, 209

compression of, 209

variations in, 212

Dorsal interosseous muscles. See

Interosseous muscle(s), dorsal

Dorsal ladder, of venous system, 644, 645f

Dorsal metacarpal branches, of radial artery,

266

Dorsal plate, 649

Dorsal sensory branch, of ulnar nerve, 431,

434f

Dorsal sensory nerve, 573

Dorsal skin branches, of digital arteries,

560–561, 561f

Dorsoepitrochlearis muscle, 105

Dorsoradial capsule injury, 627

Dorsoradial ligament, of thumb, 538t,

539–540, 539f

Drop finger (mallet finger), 652, 653f, 658

Duchenne’s sign, 676

Dupuytren’s contracture, 619–622, 620f,

621f, 622t, 623f, 676

Dysostosis, clavicular, 8

E

ECRB muscle. See Extensor carpi radialis

brevis muscle

ECRL muscle. See Extensor carpi radialis

longus muscle

ECU muscle. See Extensor carpi ulnaris

muscle

EDC muscle. See Extensor digitorum

communis muscle

EDM muscle. See Extensor digiti minimi

muscle

Egawa sign, 676

EIP muscle. See Extensor indicis proprius

muscle

Elbow, 365–406. See also specific structures,

e.g., Humerus, distal; Ulna,

proximal

anatomic relationships of, 368–374,

368f–369f, 370t, 371f, 373f, 374f

anomalies and variations of, 405

arteries of, 368, 368f–369f, 370, 370t

articulations of, 365, 366

axis of rotation of, 374, 374f

capsular attachments of, 31f–32f

capsule of, 370

surgical exposure of, 374, 384f, 385,

385f

carrying angle of, 365–366

clinical correlations of, 386–405

cubital tunnel of. See Cubital tunnel;

Cubital tunnel syndrome

descriptive anatomy of, 365–366, 366f,

367f

dislocation of, 386–387, 386f, 398–399

fat pads of, 31f, 370, 387, 387f

flexion contracture of, 403–405, 404f

flexion of, test for, 676–677

fractures of. See also specific bones

radiography of, 386–387, 386f, 387f

surgical exposures for, 382–383, 382f

golfer’s, 26–27, 388

heterotopic ossification of, 405

imaging of, 386–387, 386f, 387f

landmarks of, 365, 366f

ligaments of, 31f–32f, 370–374, 371f,

373f, 374f

injuries of, 399–403, 399f, 401f–403f

motion of, for activities of daily living,

386

myositis ossificans of, 405

posterolateral rotatory instability of,

400–402, 402f, 403f

pulled, 399

skeletal anatomy of, 365–367, 367f

snapping, 398

subluxation of, 399

surgical exposures for, 374–385

in flexion contracture, 403–405, 404f

Kocher or lateral “J” approach, 374,

384f, 385, 385f, 403–405, 404f

lateral approach, 382–383, 382f, 383f

for lateral collateral ligament

reconstruction, 402, 403f

medial approach, 379–380, 380f, 381f

in medial collateral insufficiency, 400,

401f

posterior approach, 374–377,

375f–377f

radial head approach, 377–378, 378f,

379f

tennis, 26, 388

ulnar nerve in. See Ulnar nerve, in elbow

and forearm

valgus load on, 372

700 Subject Index

Digital artery(ies) (contd.)

Elbow disc, 105

Elevated arms stress test, 688

Elson test, 659, 659f, 677

Emboli, radial artery, 269

EPB muscle. See Extensor pollicis brevis

muscle

Epicondyles, of humerus. See Humerus,

epicondyles of

Epitrochleoanconeus ligament, 456

Epitrochleoanconeus muscle, 124, 208

Epitrochleocubital muscle, 106

Epitrochleoolecranonis anconeus

epitrochlearis muscle, 106

Epitrochleoolecranonis anconeus muscle,

124

EPL muscle. See Extensor pollicis longus

muscle

Eponychium, 654f

Erb-Duchenne palsy, 677

Erb’s point, 300f, 304, 304f

Essex-Lopresti fractures, 36, 40, 413,

677–678

Expansion, extensor (aponeurosis),

135–136, 136f, 137f

Extensor aponeurosis, 135–136, 136f, 137f

Extensor atque abductor pollicis accessorius

muscle, 146

Extensor carpi radialis accessorius muscle,

132

Extensor carpi radialis brevis muscle, 114t,

133–134, 181t, 465

innervation of, 427–429

in “mobile wad of three,” 408, 408f, 422,

422f, 461, 462f

origin of, 429, 429f, 430f

radial nerve branch to, 427–429

radial nerve compression by, 478, 479f,

480

radial nerve injury effects on, 220

Extensor carpi radialis brevis tendon, in

intersection syndrome, 480, 482f,

483

Extensor carpi radialis intermedius muscle,

132, 132f, 134, 484, 664, 664f

Extensor carpi radialis longus muscle, 114t,

130–133, 181t, 464f, 465

actions and biomechanics of, 131

anomalies and variations of, 131–132,

132f

clinical implications of, 132–133

in extensor retinaculum, 506

gross anatomy of, 131

innervation of, 426, 427f, 428t

as landmark, 316f

in “mobile wad of three,” 408, 408f, 422,

422f, 461, 462f

radial nerve injury effects on, 220

Extensor carpi radialis longus tendon, in

intersection syndrome, 480, 482f,

483

Extensor carpi ulnaris muscle, 114t,

143–144, 181t, 464f, 466

in extensor retinaculum, 506

identification of, 461, 463f

innervation of, 428t

radial nerve injury effects on, 220

Extensor compartment artery, 515, 516f

Extensor digiti minimi muscle, 142–143,

181t, 464f, 465–466

anomalies and variations of, 663–664

identification of, 461, 463f

innervation of, 428t

juncturae tendinum attachment to,

649–651, 650f, 651f

Extensor digiti minimi tendons, 138t,

648–649

Extensor digiti quinti muscle. See Extensor

digiti minimi muscle

Extensor digiti quinti (extensor digiti

minimi) tendons, 138t, 648–649

Extensor digitorum breves manus tendons,

138t

Extensor digitorum brevis manus muscle,

139, 140f, 141, 662–663, 663f

Extensor digitorum communis muscle,

134–141, 181t, 464f, 465, 591f

actions and biomechanics of, 138–139,

138t

anomalies and variations of, 138t, 139,

140f, 141, 663–664

clinical implications of, 141

extensor digiti minimi association with,

142–143

gross anatomy of, 135–138, 136f, 137f

identification of, 461, 463f

innervation of, 427, 428t

juncturae tendinum of, 135–136, 137f,

139, 141

vascularity of, 134

Extensor digitorum communis tendons

anatomy of, 649

anomalies and variations of, 139, 140f,

141

juncturae tendinum attachment to,

649–651, 650f, 651f

Extensor expansion (aponeurosis), 135–136,

136f, 137f

Extensor function, digital, loss of,

differential diagnosis of, 221

Extensor hood

lumbrical muscle insertion into, 159

palmar interosseous muscles insertion

into, 588

Extensor indicis et medii communis muscle,

139, 140f, 484–485, 661–662, 662f

Extensor indicis proprius muscle, 141–142,

181t, 465f, 466

innervation of, 427, 428t

Extensor indicis proprius syndrome, 483,

678

Extensor indicis proprius tendons, 138t,

652–654

anatomy of, 648–649

anomalies and variations of, 663–664

transfer of, junctura tendinum and,

651–652

Extensor medii et annularis communis

muscle, 139

Extensor medii proprius muscle, 138t, 139,

140f, 484, 661–662, 661f

Extensor plus syndrome or test, 678

Extensor pollicis brevis muscle, 181t,

147–148, 465f, 466

innervation of, 428t

in intersection syndrome, 480, 482f, 483

as landmark, 461, 462f

Extensor pollicis brevis tendon

anatomy of, 648–649

in de Quervain’s tenosynovitis, 476–477,

477f, 478f

Extensor pollicis longus muscle, 148–149,

181t, 465f, 466

innervation of, 427, 428t

Extensor pollicis longus tendon

anatomy of, 648–649

dislocation of, 149

as landmark, 461, 462f

tenosynovitis of, 483–484

Extensor retinaculum, 647–648, 648f

anatomy of, 504–505, 505f

extensor digitorum communis tendons

in, 135

function of, 505

surgical exposures for, 518, 518f

tendons of, 505–506

Extensor tendons. See also specific tendons

accessory, 664, 664f

anatomy of, 648–649

anomalies and variations of, 663–664,

664f

arrangement of, 649

germinal matrix relationship to, 656

sagittal band attachment to, 652

zones of injury of, 649, 649f

Extrinsic extensor muscles, 590–592,

590f–592f

F

Fascia

digital, 598–599, 598f, 599f

fibrofatty, in Dupuytren’s contracture,

621

of finger, pathologic anatomy of,

620–622

of flexor retinaculum, 503–504, 503f

palmar, 115–116, 595–597, 596f, 597f,

619, 620f

Fasciotomy, for compartment syndrome

of forearm, 451, 451f

of hand, 635–636, 635f

Subject Index 701

Fat pads, elbow, 31f, 370, 387, 387f

FCL muscle. See Flexor carpi ulnaris muscle

FCR muscle. See Flexor carpi radialis muscle

FDP muscle. See Flexor digitorum

profundus muscle

FDS muscle. See Flexor digitorum

superficialis muscle

Fibrofatty fascia, in Dupuytren’s

contracture, 621

Fibrous bands, radial nerve compression by,

478, 479f

Finger(s). See also subjects starting with

Digital

anomalies and variations of, 661–664,

661f–664f

arteries of, 560–568, 561f, 562t, 563f,

565f, 567f. See also specific arteries

boutonniere lesion in. See Boutonniere

deformity

carpometacarpal joints of. See

Carpometacarpal joint(s)

closed sagittal band injury of, 660–661

collateral ligaments of, injuries of,

625–627, 625f

creases of, 488f, 533, 533f, 534f

digital arteries of. See Digital artery(ies)

digital web spaces of, 560

drop (mallet), 652, 653f, 658

extensor function loss in, differential

diagnosis of, 221

extensor tendons of, 648–649, 649f. See

also specific tendons

anomalies and variations of, 663–664

functional dynamics of, 652

imbalance of, 652, 653f

fascia of, 598–599, 598f, 599f

pathologic anatomy of, 620–622

index

arteries of, 562–568, 562t, 563f, 565f,

567f

carpometacarpal joint of, 540

digital nerves of, 573

dorsal interosseous muscles of, 162,

163, 584–587, 584f–586f

lumbrical muscles of, 587f, 588

metacarpal arteries of, 562–563, 563f,

565f, 568

metacarpal of, 64–65, 65t, 68–71, 69f,

131, 536

metacarpophalangeal joint of,

dislocation of, 628–630, 629f,

630f

muscle origins and insertions of,

135–136, 137f, 138, 138t

palmar interosseous muscles of,

164–165, 587–588, 587f

phalanges of, 79, 82

radial collateral ligament of, surgical

exposures for, 617, 619f

radial deviation of, 545t

ray of, 535–536

synovial sheath of, 603f

ulnar deviation of, 545t

intermetacarpal joints of, 540–549,

541f–548f, 545t. See also

Interphalangeal joint(s);

Metacarpophalangeal joint(s)

interphalangeal joints of. See

Interphalangeal joint(s)

intrinsic plus or minus, 159, 164, 595

long

arteries of, 562, 562t

carpometacarpal joint of, 540

dorsal interosseous muscles of, 162,

163, 584–587, 584f–586f

lumbrical muscles of, 587f, 588

metacarpal of, 64–65, 65t, 71–74, 72f,

536

extensor carpi radialis insertion into,

133

styloid process of, 487, 487f, 642,

643f

muscle origins and insertions of,

135–136, 137f, 138, 138t

palmar interosseous muscles of,

587–588, 587f

phalanges of, 79, 81, 82, 83

radial deviation of, 545t

ray of, 535–536

sagittal band injury of, 660–661

synovial sheath of, 603f

testing of, in radial tunnel syndrome,

478

ulnar deviation of, 545t

vincula of, 610f–611f

lumbrical plus, 159–160, 595, 684

mallet, 652, 653f, 658

metacarpals of. See Metacarpal(s)

metacarpophalangeal joints of. See

Metacarpophalangeal joint(s)

middle. See Finger(s), long

nail units of, 654–656, 654f, 655f

phalanges of. See Phalanges

proprius tendons of, 652–654

pulley system of. See Pulley system

radial deviation of, 545t

rays of, 535–536

ring

arteries of, 562, 562t

carpometacarpal joint of, 540

dorsal interosseous muscles of, 162,

163, 584–587, 584f–586f

lumbrical muscles of, 587f, 588

metacarpal of, 64–65, 65t, 74–77, 75f,

536

muscle origins and insertions of,

135–136, 137f, 138, 138t

palmar interosseous muscles of,

164–165, 587–588, 587f

phalanges of, 81, 82, 83

radial deviation of, 545t

ray of, 535–536

sensory innervation of, 211–212

synovial sheath of, 603f

ulnar deviation of, 545t

ulnar nerve motor branch to, 206

skin coverage of, 643

small

arteries of, 562, 562t

carpometacarpal joint of, 540

digital artery to, 258–259

dorsal interosseous muscles of,

584–587, 584f–586f

extensor mechanism of, 591f

lumbrical muscles of, 587f, 588

metacarpal of, 64–65, 65t, 77–79, 77f,

143, 536

muscle origins and insertions of,

135–136, 137f, 138, 138t

palmar interosseous muscles of,

164–165, 587–588, 587f

phalanges of, 81, 82, 83

radial deviation of, 545t

ray of, 535–536

sensory innervation of, 211–212

synovial sheath of, 603f

ulnar deviation of, 545t

ulnar nerve motor branch to, 206

surgical exposures for, 656–658, 657f,

658f

in elective procedures, 613–614, 613f,

614f

in laceration repair, 614–615, 615f

swan neck deformity of, 652, 653f, 660

trigger, 622–624

ulnar deviation of, 545t

venous system of, 644–647, 644f, 645f

web spaces between, arterial supply of,

560

Finkelstein’s test, 476–477, 477f, 678–679

Finochietto-Bunnell test, 682–683

Flexion creases, 532–535, 533f, 534f

of fingers, 488f, 533, 533f, 534f

of wrist, 488f, 489, 489f, 533f, 534, 534f

Flexor carpi radialis brevis muscle, 115, 134,

456

anterior interosseous nerve compression

at, 447, 448f

as donor muscle, 115

Flexor carpi radialis muscle, 111–115, 180t,

416, 417f

actions and biomechanics of, 114

anomalies and variations of, 456

clinical correlations of, 115

in extensor retinaculum, 506

gross anatomy of, 112–114, 112f, 113f,

114t

identification of, 422, 423f

Flexor carpi radialis tendon, 113

skin reference lines for, 535f

702 Subject Index

Flexor carpi ulnaris muscle, 114t, 123–125,

180t, 416, 417f

accessory, 214

anomalies and variations of, 456

in extensor retinaculum, 506

hypertrophy of, 214

identification of, 422, 423f

innervation of, 207

Flexor digiti minimi muscle, 156, 182t,

583, 583f

accessory, 214

Flexor digiti quinti (flexor digiti minimi)

muscle, accessory, 214

Flexor digitorum profundus indicis muscle,

127

Flexor digitorum profundus muscle,

125–127, 181t, 421

anomalies and variations of, 457

innervation of, 198, 207

ulnar nerve motor branch to, 206

Flexor digitorum profundus tendon, 421,

607f, 608

in carpal tunnel, 504

vascular supply of, 609

Flexor digitorum sublimis (flexor

digitorum superficialis muscle),

120–123, 180t

Flexor digitorum superficialis muscle,

120–123, 180t, 416, 418f, 419,

419f, 421

accessory, 122

accessory motor supply to, 191

anomalies and variations of, 456

anterior interosseous nerve compression

at, 447, 448f

anterior interosseous nerve innervation

of, 190–191, 193–194

digastric, 122

median nerve compression at, 445–446,

446f, 447f

Flexor digitorum superficialis tendon, 420f,

421, 607f, 608, 608f

in carpal tunnel, 504

transfer of, 611

vascular supply of, 609

Flexor indicis profundus muscle, 127

Flexorplasty, Steindler, 101

Flexor pollicis brevis muscle, 152–153,

182t, 582–583, 582f

innervation of, 211

Flexor pollicis longus muscle, 127–129,

181t, 420f, 421

accessory (Gantzer’s muscle), 128, 191,

419f, 420f, 457

anterior interosseous nerve

compression at, 447, 448f, 449

anomalies and variations of, 457

in Linburg-Comstock anomaly, 684

Flexor pollicis longus tendon, 421, 607, 607f

nodular thickening of, 623

Flexor-pronator origin (aponeurosis), 392

Flexor retinaculum, 503–504, 503f

muscle origins and insertions of

abductor pollicis brevis, 149–150

flexor digiti minimi, 156

opponens pollicis, 153

palmaris brevis, 155

Flexor tendons, 607–612, 607f–611f. See

also specific tendons

rupture of, 624–625, 624f

sheaths of

patterns of, 602–604, 605f

in pulley system, 600–602, 600f

vascular supply of, 608–612

clinical significance of, 611–612

sources of, 608–609

terminology of, 608

of thumb, 611

vincular patterns in, 609, 610f–611f,

611–612

FLP muscle. See Flexor pollicis longus

muscle

Forearm. See also specific structures

cross-section of, 417f, 418f, 420f, 450,

450f

dorsal, 461–485

anomalies and variations in, 484–485

clinical correlations of, 476–484

de Quervain’s tenosynovitis and. See de

Quervain’s tenosynovitis

descriptive anatomy of, 461

extensor indicis proprius syndrome in,

483

extensor pollicis longus tenosynovitis

in, 483–484, 484f

intersection syndrome in, 133, 134,

146–148, 480, 482f, 483

landmarks of, 461, 462f

muscles of, 461–466

anomalies and variations of,

484–485

deep, 461, 464f, 465f, 466

identification of, 461, 463f

intersection zones of, 464f, 466

“mobile wad of three,” 408, 408f,

422, 422f, 461, 462f

superficial, 461, 464f, 465–466

posterior interosseous nerve syndrome

in, 480

radial neuritis in, 480, 481f

radial tunnel syndrome in. See Radial

tunnel syndrome

surgical exposures for, 467–476

flaps of

radial artery in, 269

ulnar artery in, 261

flexor, 407–460

anomalies and variations of, 453–458,

453f, 454f

anterior interosseous nerve syndrome

in. See Anterior interosseous nerve

syndrome

arteries of, 423–424, 424f, 431, 434f,

457–458

biceps tendon rupture in, 451, 452f

clinical correlations of, 445–461,

446f–448f, 450f–452f

compartment syndrome of, 449–451,

450f, 451f

cutaneous nerves of, 413–416, 415f

descriptive anatomy of, 407–413

landmarks, 407–408, 408f

skeletal, 408–413, 409f, 411f, 412f

muscles of, 416–423

anomalies and variations of, 453–457

in antecubital fossa, 422–423, 424f

deep group, 421–422, 420f–422f

dorsolateral, 407

intermediate group, 416, 418f, 419,

419f, 421

“mobile wad of three” group, 408,

408f, 422, 422f, 461, 462f

pronation/supination, 407

superficial, 416, 417f

ventromedial, 407

nerves of, 424–431, 426f, 427f, 428t,

429f, 430f, 432f, 434f

anomalies and variations of,

453–457, 453f, 454f

cutaneous, 413–416, 415f

pronator syndrome in. See Pronator

syndrome

surgical exposures for, 435–444

antecubital fossa, 435–438,

435f–437f

distal, 441, 444, 444f

lateral antebrachial cutaneous nerve,

444, 445f

median nerve, 438, 440–441,

441f–444f, 444

radial shaft, 438, 439f–440f

ulnar nerve, 438, 440–441,

441f–443f

veins of, 413, 414f

lateral antebrachial cutaneous nerve of,

222–223

medial cutaneous nerve of. See

Antebrachial cutaneous nerve,

medial

median nerve in. See Median nerve, in

forearm

muscles of. See also Forearm, extensor,

muscles of; Forearm, flexor, muscles of

ulnar nerve compression in, 391–392

musculocutaneous nerve in, 222–223

radial nerve in, 216–222, 216t, 217t

ulnar nerve in. See Ulnar nerve, in elbow

and forearm

veins of, 273f, 275–276

Forearm axis artery, 197

Subject Index 703

Fossa

antecubital. See Antecubital fossa

coronoid, of humerus, 21f, 24

lunate, 487, 487f, 490, 490f, 642, 643f

olecranon, 20f, 24, 319f, 366, 367f

radial, 21f, 366, 367f

FPL muscle. See Flexor pollicis longus

muscle

Fracture(s)

vs. accessory bones, 35–36

backfire, 41, 675

Barton’s, 41, 671

Bennett’s, 671–672

chauffeur’s, 41, 675

clavicular, 7

Colles’, 36, 40–41, 675

compartment syndrome in, 449–451,

451f, 452f

de Quervain’s, 675–676

elbow, radiography of, 386–387, 386f,

387f

Essex-Lopresti, 36, 40, 413, 677–678

Galeazzi, 36, 40, 679

hamate, 56–57

Holstein-Lewis, 26, 216, 356, 681–682

humeral. See Humerus, fractures of

lorry driver’s, 41, 675

Monteggia, 35, 685

nightstick, 35

olecranon, 35

Piedmont (Galeazzi), 36, 40, 679

pisiform, 55

radial. See Radius, fractures of

Rolando, 687

scaphoid, 49

Seymour’s, 688

Smith’s, 41, 688

styloid process, ulnar, 35

Tenosynovitis, 675–676

of thumb, 626, 671–672, 687

Thurston Holland’s fragment in, 690

trapezium, 62

trapezoid, 61

triquetrum, 54

ulnar. See Ulna, fractures of

wrist, de Quervain’s, 675–676

FREAS mnemonic, for radial tunnel

compression sites, 478, 479f

Free nerve endings, 225f

Frohse, arcade of, 144–145, 217, 429–430,

429f, 670

radial nerve branches above, 429, 430f

radial nerve compression by, 478, 479f

Froment-Rauber anastomosis, 219

Froment-Rauber nerve, 219

Froment’s sign, 679

G

Galeazzi’s fracture, 36, 40, 679

Gamekeeper’s thumb, 679

Ganglions, in ulnar tunnel, 213

Gantzer’s muscle (accessory flexor pollicis

longus muscle), 128, 419f, 420f,

457

anterior interosseous nerve compression

at, 447, 448f, 449

anterior interosseous nerve innervation

of, 191

Germinal matrix, of nail bed, 654–656,

654f

Glenohumeral joint, 17, 24

Glenoid

ossification center for, 9

osteology of, 10, 12f–14f, 15t, 17

Golfer’s elbow, 26–27, 388

Grasp, intrinsic muscle function in, 164,

592–593, 593f

Graves’ scapula, 8

Grayson’s ligaments, 596f–597f, 598, 598f,

620f, 621f, 622, 679–680

Gruber, anconeus sextus of, 124

Guyon’s canal, 555, 556f, 680

anatomy of, 575, 576f, 577

clinical correlations of, 212–214, 213t

skin dimpling at, in Ollier’s

phenomenon, 686

surgical exposures for, 522, 525f–526f,

527

ulnar artery in, 555, 556f, 576

ulnar nerve in, 209–210

compression of, 577, 578t

variant, 213

zones of, 577, 578t

H

Haines-Zancolli test, 680–681

Hamate, 41f, 42f, 55–57, 491f

accessory bones of, 55, 57

clinical correlations of, 56–57

derivation and terminology of, 55

fractures of, 56–57

hook of, 488

bipartite, 529

joints associated with, 56

ligaments of, 494

muscle origins and insertions of, 56

ossification centers of, 43f, 55

osteology of, 55–56, 55f, 494

skin reference lines for, 535f

surgical exposures for, 522, 525f–526f,

527

vascularity of, 56, 494, 513

Hamulus, bipartite, 529

Hand. See also Finger(s); Thumb; specific

structures

arteries of, 549–568. See also specific

arteries

carpometacarpal joints of. See

Carpometacarpal joint(s)

claw deformity of, 221, 593, 593f

cross-section of, 634f, 635f

dorsal, 642–666

anatomic relationships of, 642–656

anomalies and variations of, 661–664,

661f–664f

boutonniere lesion in. See Boutonniere

deformity

carpometacarpal bossing in, 661

clinical correlations of, 658–664

closed sagittal band injuries in,

660–661

descriptive anatomy of, 642–643, 643f

extensor retinaculum of. See Extensor

retinaculum

extensor tendons of, 648–649, 649f

functional dynamics of, 652

imbalance of, 652, 653f

juncturae tendinum of, 649–652,

650f, 651f

landmarks of, 642–643, 643f

mallet finger in, 652, 653f, 658

nail unit of, 654–656, 654f, 655f

proprius tendons of, 652–654

proximal interphalangeal joint dorsal

plate of, 649

sagittal bands of, 652

skin coverage of, 643, 642–656

surgical exposures for, 656–658,

657f–658f

swan neck deformity in, 652, 653f,

660

venous system of, 644–647, 644f,

645f

intermetacarpal joints of, 540–549,

541f–548f, 545t. See also

Interphalangeal joint(s);

Metacarpophalangeal joint(s)

interphalangeal joints of. See

Interphalangeal joint(s)

median nerve in. See Median nerve, in

wrist and hand

palmar, 532–641

anomalies and variations of, 636–638,

636f, 637f

arches of, 536, 536f

arteries of, 549–568. See also specific

arteries

carpometacarpal joints of. See

Carpometacarpal joint(s)

clinical correlations of, 619–636

creases of, 488f, 489, 489f, 532–534,

533f, 534f

cutaneous nerves of, 568–570, 569f

deep palmar arch of. See Palmar arches,

deep

descriptive anatomy of, 532–549

digital nerves in. See Digital nerves

dorsal carpal arch in, 549–550, 551f,

552f

dorsal metacarpal arteries of, 550

704 Subject Index

flexor tendon synovial sheath patterns

in, 602–604, 605f

intermetacarpal joints of. See

Intermetacarpal joint(s)

joint innervation in, 572–573

landmarks of, 532–535, 533f

median nerve in, 570, 571f, 572, 572f,

575, 575t

metacarpal arteries of, 553–555

metacarpals of. See Metacarpal(s)

muscles of, 581–595

nerves of, 568–581

persistent median artery in, 555, 556f,

557, 558f, 559

phalanges of. See Phalanges

pulley system of, 599–602, 600f, 603f,

604t

radial artery in, 549, 550f

rays of, 535–536

retinacular system of, 595–599,

596f–699f

skeletal anatomy of, 535–549. See also

individually named bones

skin reference lines on, vs. deeper

structures, 535, 535f

spaces in, 604–607, 606f

surgical exposures for, 612–619

elective incisions in, 613–614, 613f,

614f

general principles of, 612–613, 613f

for joints, 615–619, 616f–619f

in laceration repair, 614–615, 615f

tendons of, 607–612, 607f–611f

thenar nerve in, 573–574, 574t

ulnar artery in, 555, 556f, 557, 558f,

559, 559f

ulnar nerve in, 575–581, 576f–578f,

578t, 580f, 581f

phalanges of. See Phalanges

radial nerve in. See Radial nerve, in

forearm and hand

ulnar nerve in. See Ulnar nerve, in wrist

and hand

Henle, nerve of, 201f, 569, 569f, 681

anomalies and variations of, 455

Henry, leash of, radial nerve compression

by, 478, 479f

Henry’s manual mnemonic, for superficial

forearm muscles

extensor, 461, 463f

flexor, 422, 423f

Heterotopic calcification and ossification, of

elbow, 405

High division axillary anomaly, 243, 244

Hill-Sacks lesion, 25–26

Hoffman-Tinel sign, 681

Holstein-Lewis fracture, 26, 216, 356,

681–682

Hook grasp, intrinsic muscle function in,

593, 593f

Horner’s syndrome, 304, 682

Hotchkiss classification, of radial head

fractures, 40

Huber transfer, 156, 682

Hueter’s line, 317, 319f, 410

radial nerve branches above, 426, 427f,

429f

Hulten’s variance, 36, 498

Humeral circumflex artery

accessory arteries from, 332, 333f

anterior, 238f, 239f, 242

posterior, 238f, 239f, 242–244, 331f

Humerus, 18–27

anatomic neck of, 18, 20, 20f, 21f, 25

articular components of, 408–409

in Bankart lesion, 26

bicipital groove of, 20, 21f, 23

bicipital ridges of, 20

capitulum of, 21f, 23f, 24, 319f, 366,

367f

ossification centers for, 18, 19f

osteochondrosis of, 27

radiography of, 386–387, 386f, 387f

clinical correlations of, 25–27

condyles of, fractures of, 386–387, 386f

coronoid fossa of, 21f, 24

cross-section of, 319f

deltoid tuberosity of, 23, 317, 319f

derivation and terminology of, 18

distal, 366, 367f

arteries of, 332

fractures of, 334

ossification centers for, 18, 19f

osteology of, 20f–23f, 24, 408–410

epicondyles of, 20f, 21f, 23f, 24, 366,

367f

extensor digitorum communis

attachment to, 135–136

inflammation of, 26–27, 388

as landmarks, 315, 316f–318f, 365,

366f, 408, 408f, 461, 462f

muscle origins and insertions of, 105

extensor carpi radialis brevis, 133

extensor carpi ulnaris, 143

extensor digiti minimi, 142

extensor digitorum communis, 135

flexor carpi radialis, 112–113

palmaris longus, 115–116

supinator, 144

ossification centers for, 18, 19f

osteotomy of, 380, 381f

epiphyseal lines of, 19f

fractures of, 25, 26

blood supply and, 332, 334

Holstein-Lewis, 26, 216, 356,

681–682

radiography of, 386–387, 386f, 387f

supracondylar, 26

surgical exposures for. See Humerus,

surgical exposures for

transphyseal, 386–387, 386f

grooves of, 20, 21f, 23, 319f

head of

arteries of, 332, 333f

fractures of, 334

in Hill-Sacks lesion, 25–26

in impingement syndrome, 25

intraosseous arterial supply of, 332, 332f,

334

joints associated with, 24

landmarks of, 319f

in lateral epicondylitis, 26, 388

in medial epicondylitis, 26–27, 388

medullary canal of, 18

metastasis to, blood supply and, 334

muscle origins and insertions of, 25, 315,

317

brachialis, 102

brachioradialis, 106, 110

coracobrachialis, 96

deltoid, 92, 95f, 97

extensor carpi radialis longus, 131

flexor carpi ulnaris, 123

flexor digitorum superficialis, 120–121

pronator teres, 110–111

triceps brachii, 103–104

nutrient canal of, 23–24

olecranon fossa of, 20f, 24, 319f, 366, 367f

ossification centers of, 18, 19f

osteochondrosis of, 27

osteology of, 18–24, 20f–23f, 315,

317–318, 319f, 408–410

principal nutrient artery of, 246

proximal

fractures of, 25

ossification centers for, 18, 19f

osteology of, 18, 20, 20f–23f

radial fossa of, 21f, 366, 367f

radial sulcus of, 20f, 22f, 23, 24

ridges of, 319f

shaft of, 315

arteries of, 332, 333f, 334

fractures of, 26, 332, 334

osteology of, 20f–22f, 23–24

in shoulder dislocation, 25, 26

supracondylar fractures of, 26

supracondylar process of, 26, 188

supracondylar ridges of, 20f, 21f, 24,

319f, 366, 367f

as landmarks, 461, 462f

surfaces of, 315, 317–318, 319f

surgical exposures for, 374–377,

375f–377f

anterior approach, 341, 342f–344f

anterolateral approach, 341, 343, 345,

345f, 346f

distal, 374–377, 375f–377f

posterior, 351–353, 350f–353f

proximal posterior approach, 353,

354f, 355f

Subject Index 705

surgical neck of, 18, 20, 20f, 21f, 25, 306

torsion of, 318, 319f

trochlea of, 20f, 21f, 23f, 24, 319f, 366,

367f

tuberosities of, 23, 24, 315, 317, 319f

ossification centers for, 18, 19f

osteology of, 20, 20f–22f

vascular supply of, 332, 332f, 334

Hurler’s syndrome, trigger digits in, 624

Hyponychium, 654f, 655

Hypothenar compartment, compartment

syndrome of, 633–634

Hypothenar eminence, 488f, 489, 532,

533f

Hypothenar hammer syndrome, 260

Hypothenar muscles, 503f, 583–584, 583f.

See also specific muscles

anomalies of, 214

arteries to, 267f

innervation of, 578f, 579

vascularity of, 508f

I

Impingement syndrome

acromion in, 17

humerus in, 25

Incisions. See Surgical exposures

Index finger. See Finger(s), index

Infarction, muscle, in compartment

syndrome, 449–450

Infraglenoid tubercle, 16

Injury. See specific anatomic structure

Intercapitular veins, 270, 271, 271f, 272f,

644f

Intercarpal arches, 46f–49f, 53

basal, 253f

dorsal, 253f, 265–266, 265f, 506, 507f,

508f, 509, 509f, 512, 515, 516f,

551f

in hamate vascularity, 56

palmar, 254, 255f, 264, 507, 508f, 512

Intercarpal arteries, 45–46, 46f–49f, 511

Intercarpal ligaments, 492

dorsal, 492, 500, 500f, 538–539, 538t,

539f

palmar, 538, 538t, 539f

Interclavicular ligament, 6–7, 6f

Intercompartmental arteries, of wrist,

514–516, 516f, 517f

Intercostobrachial cutaneous nerve, 325f

Intercostobrachial nerve, 202f–203f

medial brachial cutaneous nerve

communication with, 224

Interepicondylar (Hueter’s) line, 317, 319f,

410

radial nerve branches above, 426, 427f,

429f

Interfossal ridge, of radius, 490, 490f

Intermediate septa, of hand, 604, 606f

Intermetacarpal joint(s), 540–549,

541f–548f, 545t. See also

Interphalangeal joint(s);

Metacarpophalangeal joint(s)

Intermuscular septa, of arm, 326f, 327,

329f–331f, 394–395, 394f–396f

Interosseous artery(ies)

anterior, 238f, 245f, 249f, 251, 252,

253f, 368f

dorsal branch of, 509–510

palmar branch of, 509–510

palmar carpal branch of, 249f

in triangular fibrocartilage supply, 497,

498f

in wrist and hand, 508f, 509–510,

514–516, 516f–517f

common, 238f, 245f, 250–252, 368f

in antecubital fossa, 425f

high division of, 259–260

posterior, 238f, 245f, 249f, 252, 253f,

368f, 510f, 511f

at wrist, 514–516, 516f–517f

recurrent, 245f, 249f, 252, 253f, 368f,

369f, 370t

Interosseous compartment, compartment

syndrome of, 634f, 635, 635f

Interosseous joints, of wrist, 494–495

Interosseous ligaments, 33, 502–503

Interosseous lymph vessels, 278

Interosseous muscle(s), 584–588

dorsal, 584–587, 584f–586f, 588f

deep head of, 585f, 585–587

functions of, 587

insertions of, 582, 584f, 586f, 587

superficial head of, 584f, 585–587

palmar, 581–582, 587–588, 587f

Interosseous nerve(s)

anterior

anomalies and variations of, 446–447

compression of. See also Anterior

interosseous nerve syndrome

in forearm, 193–194

course of, 189

flexor digitorum superficialis and,

193–194

in forearm, 431, 432f, 433f

Martin-Gruber anastomosis and, 193

posterior interosseous nerve

communication with, 222

sympathetic fibers in, 188

variations of, 190–191

posterior, 217–218, 217t, 427f

anterior interosseous nerve

communication with, 222

clinical correlations of, 220–221

course of, 431

evaluation of, 221

fibrous tissue arcades and, 429, 429f,

430f

protection of, in elbow surgery, 378

safe and unsafe internervous planes

and, 221

surgical exposures for, 467–472,

467f–472f

syndrome of, 480

vs. radial tunnel syndrome, 477–478

Interosseous recurrent artery, 331f

Interosseous veins, 276

Interosseus membrane, 410–413

clinical correlations of, 412–413

function and biomechanics of, 411–412

gross anatomy of, 410, 411f

histology of, 410–411

Interosseus muscle(s)

dorsal, 158t, 160–164, 182t

actions and biomechanics of, 162–163

anomalies and variations of, 163

clinical correlations of, 163–164

gross anatomy of, 160–162

innervation of, 160, 162

origin and insertion of, 160

vascular supply of, 160

palmar, 158t, 164–165, 183t

Interphalangeal joint(s)

distal, 84, 549

flexion of, in swan neck deformity,

652, 653f, 660

surgical exposures for, 657–658, 658f

venous system at, 644f, 645

extension of

in Bouvier’s sign, 672

lumbricals in, 158–159, 158t

flexor pollicis longus action on, 128

Froment’s sign in, 679

proximal, 81f, 82, 545–547

contracture of, 632–633, 633f

dislocation of, 631–632, 631f

dorsal plate at, 649

extensor mechanisms at, 652

disruption of, 652, 653f

extensor tendon disruption at. See

Boutonniere deformity

hyperextension of, in swan neck

deformity, 652, 653f, 660

innervation of, 572–573

ligaments of, 546–547, 546f–548f

paradoxical extension of, 159–160

rotary subluxation of, 631, 631f

skin creases at, 533

surgical exposures for, 617, 619, 657,

658f

tightness of, 594–595, 594f

type of, 545–546, 545f

venous system at, 644f, 645

thumb, 86

Interphalangeal transverse digital artery,

609, 610f

Intersection syndrome, 133, 134, 146–148,

480, 482f, 483

Intersection zones, in forearm, 466

706 Subject Index

Humerus (contd.)

Interspaces, finger, arterial supply of, 560

Intrinsic function, 164

Intrinsic longitudinal vessels, from palm,

608–609

Intrinsic minus position, 159, 164, 595

Intrinsic muscle(s), 584–590, 584f–588f.

See also specific muscles

angle of attack of, 588f, 589

architectural features of, 150, 150t, 151f,

158t, 589–590

clinical correlations of, 592–595, 593f,

594f

contracture of, 594–595, 594f

cross-section of, 589–590

dorsal interossei as, 158t, 160–164, 182t

vs. extrinsic extensor muscles, 590–592,

590f–592f

fiber lengths of, 589

function of, 592–593, 593f

lengths of, 589

lumbricals as, 157–160, 158t, 182t

weakness of, 593–594

Intrinsic plus position, 159, 164, 595

Intrinsic tightness test, 594, 594f, 682–683

J

Jeanne’s sign, 683

Jobe technique, for medial collateral

ligament reconstruction, 400, 401f

Jobe test, 399, 399f

Joint(s)

acromioclavicular, 5–6, 6f, 17

separation of, 7–8

of capitate, 58

of carpal bones, 41–42

distal row, 495

proximal row, 494–495

carpometacarpal. See Carpometacarpal

joint(s)

of elbow, 365

glenohumeral, 17, 24

of hamate, 56

of humerus, 24

interosseous, of wrist, 494–495

interphalangeal. See Interphalangeal

joint(s)

of lunate, 51

metacarpophalangeal. See

Metacarpophalangeal joint(s)

mid-carpal, 494, 501–502, 501f,

527–528, 527f, 528f

radiocapitellar, 24

radiocarpal, 489, 489f, 491, 494f, 533f,

534, 534f

radiolunate, 40

radioscaphoid, 40, 46

radioulnar. See Radioulnar joint

of radius, 31f–32f, 39–40

scaphocapitate, 46

of scaphoid, 46

scapholunate, 49

of scapula, 17

sternoclavicular, 6, 6f, 8

styloscaphoid, 40, 46

trapeziometacarpal, 489, 534

of trapezium, 62

of trapezoid, 60

triscaphe, 46, 49

of ulna, 28f–32f, 34

ulnohumeral, 24, 32f, 34, 398–399

of wrist, 494–498, 495f–498f, 527–529,

527f, 528f

Juncturae tendinum, 649–652

clinical significance of, 651–652

of extensor digitorum communis muscle,

135–136, 137f, 139, 141

types of, 649–651, 650f, 651f

K

Kapandji’s test, 683

Kaplan skin reference lines, 535, 535f

Key pinch

dorsal interossei function in, 163

Froment’s sign in, 679

Kienbˆck’s disease, 36, 52, 514

Kiloh-Neven syndrome (anterior

interosseous nerve syndrome), 127,

129, 193

Kocher or lateral “J” approach, to elbow,

374, 384f, 385, 385f, 403–405,

404f

Krause’s end bulbs, 225f

L

Lacerations, incisions for, 614–615, 615f

Lacertus fibrosus, 423, 424f

median nerve compression at, 192–193,

445–446, 446f, 447f

LACN. See Antebrachial cutaneous nerve,

lateral

Landsmeer’s ligament, 683–684, 590f–592f,

592, 683–684

Langer’s muscle, 186

Lateral bands and slips, of extensor

aponeurosis, 135, 136f, 590–592,

590f–592f

Lateral cord, in Dupuytren’s contracture,

621f, 622

Lateral digital sheet, 598

Lateral epicondylitis (tennis elbow), 26, 388

Lateral group of axillary lymph nodes, 280,

280f

Lateral ligaments, of elbow, 372–374, 373f,

374f

Lateral thoracic branch, of subscapular

artery, 239f

Latissimocondyloideus muscle, 105

Leash of Henry, radial nerve compression

by, 478, 479f

Legueu and Juvara, fibers of, 596

Lesser multangular. See Trapezoid

Ligament(s)

acromioclavicular, 6, 6f

annular, of radius, 31f, 32f, 370–371,

371f, 373f

anterior, of elbow, 370–371

anterior oblique, of thumb, 538–540,

538t, 539f

beak, of thumb, 540

of capitate, 493–494

capitohamate, 493, 494, 501f, 503

capsular, 500, 500f

carpal

palmar, 209

transverse, 503–504, 573–574

of carpal bones

distal row, 501–503

proximal row, 501f, 502

of carpometacarpal joint, 493, 494,

536–540, 537f, 538t, 539f

check-rein, 546, 546f–547f

Cleland’s, 596f–597f, 598–599, 599f,

674

collateral. See Collateral ligaments

commissural, proximal and distal, 595,

596f

conoid, 6, 6f, 10f

coracoclavicular, 6, 6f

costoclavicular, 6f, 7

dorsoradial, of thumb, 538t, 539–540,

539f

of elbow. See Elbow, ligaments of

epitrochleoanconeus, 456

of fingers, 617, 619f, 625–627, 625f

Grayson’s, 596f–597f, 598, 598f, 620f,

621f, 622, 679–680

of hamate, 494

intercarpal, 492

dorsal, 492, 500, 500f, 538–539, 538t,

539f

palmar, 538, 538t, 539f

interclavicular, 6–7, 6f

interosseous, 33, 502–503

of interphalangeal joints, 546–547,

546f–548f

Landsmeer’s, 683–684

link, 683–684, 590f–592f, 592

of lunate, 492

lunotriquetral, 492, 501f

metacarpal, transverse, 545, 604, 606f

superficial (natatory), 545, 595, 596f,

597, 597f, 598, 620, 620f, 622

metacarpophalangeal, 627

of mid-carpal joint, 501–502, 501f

natatory, 545, 595, 596f, 597, 597f, 598,

620, 620f, 622

oblique, of thumb, 538–540, 538t, 539f

oblique retinacular, 683–684, 590f–592f,

592

of pisiform, 492

Subject Index 707

pisohamate, 210, 494, 499f

pisometacarpal, 210

pisotriquetral, 492

posterior oblique, of thumb, 538t,

539–540, 539f

quadrate, 32f

radiocarpal, 492, 499–500, 499f, 500f

radiolunate, 492, 499, 499f, 500

radiolunotriquetral (long radiolunate),

499, 499f

radioscaphocapitate, 492, 493, 499, 499f

radioscapholunate, 499f, 500

radiotriquetral, 500, 500f

of radioulnar joint

distal, 496–497, 496f

proximal, 370–371

of radius, 370–371, 371f, 373f

retinacular

oblique, 590f–592f, 592, 683–684

transverse, 590f, 591, 591f

scaphocapitate, 492, 501f, 502

of scaphoid, 492

scapholunate, 492, 501f

scaphotrapezium-trapezoid, 492, 493,

501f, 502

scaphotriquetral, 500, 500f

sternoclavicular, 6–7, 6f

of Struthers, 111, 361–362, 361f, 689

vs. arcade of Struthers, 205

median nerve compression at, 188,

445, 446f, 447f

of thumb, 538–540, 538t, 539f

trapeziocapitate, 493–494, 501f,

502–503

trapeziotrapezoid, 493, 501, 501f

of trapezium, 493

trapezoid, 6, 6f, 10f, 16

of trapezoid, 493

triangular, 590f, 591

triquetrocapitate, 492, 493, 499f, 501f,

502

triquetrohamate, 492, 494, 501f, 502

of triquetrum, 492

ulnocapitate, 493, 497, 497f, 499f, 501

ulnocarpal, 497, 497f, 501

ulnolunate, 492, 497, 497f, 501

ulnotriquetral, 497, 497f, 499f, 501

of wrist. See Wrist, ligaments of

Linburg-Comstock anomaly, 684

Linburg’s sign or Linburg syndrome, 128,

129

Lister’s tubercle, 30f, 34f, 39, 461, 462f,

486, 487f, 490, 490f, 642, 643f

Loge de Guyon. See Guyon’s canal

Long finger. See Finger(s), long

Longitudinal arch, of hand, 536, 536f

Longitudinal fibers, of palmar fascia, 595,

596f–597

Lorry driver’s fracture, 41, 675

Lumbrical compartment, compartment

syndrome of, 634–635, 634f, 635f

Lumbrical muscles, 135, 157–160, 158t,

182t, 587f, 588–589, 588f

actions and biomechanics of, 158–159

anomalies and variations of, 159

clinical correlations of, 159–160

extensor digitorum communis

relationship with, 135

gross anatomy of, 157–158

innervation of, 198

Lumbrical plus digit, 159–160, 595, 684

Lunate, 41f, 42f, 491f

absence of, 527

accessory bones of, 50, 52

anomalies and variations of, 50–51, 527,

527f, 528, 528f

avascular necrosis of, 514

clinical correlations of, 52

derivation and terminology of, 50

joints associated with, 51

ligaments of, 492

ossification centers of, 43f, 50, 52

osteology of, 50, 51f, 492

vascularity of, 51–52, 492, 512, 512f

Lunate fossa, of radius, 487, 487f, 490,

490f, 642, 643f

Lunotriquetral ballottement test, 684–685

Lunotriquetral coalition, 54, 528–529

Lunotriquetral interosseous ligaments, 492

Lunotriquetral ligament, 492, 501f

Lunula, of nail unit, 654, 654f

Lymph, 277

Lymphatic system, 277–281, 277t

anomalies and variations of, 281

clinical correlations of, 281

gross anatomy of

deep nodes, 277t, 279f, 280–281, 280f

deep vessels, 277t, 278

superficial nodes, 277t, 278, 279f,

280f

superficial vessels, 277, 277t, 278f,

279f

M

McConnell approach, to median or ulnar

nerve, 440–441, 443f

MACN. See Antebrachial cutaneous nerve,

medial

Mallet finger, 652, 653f, 658

Mannerfelt hyperflexion sign, 685

Manubrium, 6–7, 6f

Martin-Gruber anastomosis, 189–190, 192

anatomy of, 454, 454f

anterior osseous nerve and, 193

clinical correlations of, 454, 454f

dorsal interossei function in, 163

types of, 453–454, 453f

Masse’s sign, 685

Matev’s sign, 685

MBCN. See Brachial cutaneous nerve(s),

medial

Medial collateral ligaments, 371–372,

371f–374f, 374, 399–400, 399f,

401f

Medial epicondylitis (golfer’s elbow), 26,

388

Median artery, 251–252

anomalies and variations of, 468

developmental anatomy of, 468

in forearm, anomalies and variations of,

468

persistent, 261, 559

in superficial arch, 257

Median lymph vessels, 277, 278

Median nerve, 185–200, 324f

anomalies and variations of, 363, 455

in antecubital fossa, 424, 424f, 431, 432f

in arcade of Struthers, 356, 357f–361f,

360t, 361–362

in axilla and arm, 329f, 330f, 340–341,

340f

anomalies and variations of, 185–186

clinical correlations of, 186, 188

course of, 185, 187f

bifid

in forearm, 191, 194

in wrist and hand, 197, 199

in brachial plexus, 299f, 301f, 304f, 306

in carpal tunnel, 196–197, 196t

common palmar digital branch of, 195

completely innervating hand, 189

compression of. See also Carpal tunnel

syndrome

in arcade of Struthers, 361–362, 361f

in axilla and arm, 186, 188

in forearm, 192–194

in pronator syndrome, 445–446, 446f,

447f

cutaneous branches of, 202f

digital nerves of

common, 199

proper, 195–196, 199

distal branching of, 196–197

in flexor digitorum profundus

innervation, 126

in flexor digitorum superficialis

innervation, 121, 191

in forearm, 426f, 431, 432f

anomalies and variations of, 189–192

anterior interosseus nerve branch of,

189–191, 193–194

clinical correlations of, 192–195

course of, 188

palmar cutaneous branch of, 189,

191–192, 194–195

in hand, branches of, 570, 571f, 572,

572f

high division of, 575, 575t

in forearm, 191, 194

708 Subject Index

Ligament(s) (contd.)

in wrist and hand, 197, 199

laceration of, with Martin-Gruber

anastomosis, 192

in lumbrical innervation, 198

in Martin-Gruber anastomosis. See

Martin-Gruber anastomosis

musculocutaneous nerve communication

with, 340, 363

origin of, 185, 186f

anomalous, 185–186

palmar cutaneous branch of, 431, 432f,

521, 521f, 524f, 568–570, 569f

absence of, 191, 194

compression of, 194

course of, 189

distal exit of, 191

injury of, 194

in palmaris longus, 191–192

peripheral block of, 195

separate branches of, 191

variations of, 191–192

palmar ulnar-median communicating

branch of Berrettini, 198, 199

palsy of, low, 593

position of, relative to ulnar nerve, 185

pronator teres branch of, 188

in pronator teres innervation, 111

protection of, in elbow surgery, 379–380,

381f

recurrent

skin reference lines for, 535f

surgical risk to, 612f, 613

recurrent motor branch of, 571f,

573–574

absence of, 197

anomalies and variations of, 573–574,

574t

anterior origin of, 197

in carpal tunnel, 196, 199

course of, 195

multiple, 196

in Riche-Cannieu anastomosis, 163,

197–198, 211, 636–637, 636f,

637f, 673–674

subligamentous origin of, 196

transligamentous passage of, 196

transretinacular pattern of, 199

from ulnar aspect, 197

ulnar-sided exit of, 197

in wrist and hand, 199

Riche-Cannieu anastomosis of, 163,

197–198, 211, 636–637, 636f,

637f, 673–674

surgical exposures for

in forearm, 438, 440–441, 441f–444f,

444

medial, 346–347, 347f–349f, 351

territory of, ulnar nerve territory

overlapping with, 190

thenar branch of, absence of, 199–200

ulnar nerve anomalous connections with,

207

in wrist and hand

anomalies and variations of, 196–198,

196t

clinical correlations of, 198–200

course of, 195–196

recurrent motor branch of, 196–197,

199

skin reference lines for, 535f

Median recurrent nerve

skin reference lines for, 535f

surgical risk to, 612f, 613

Median vein, in forearm, 413

Meissner corpuscles, 225f, 226

Meniscus, of radioulnar joint, 497

Merkel receptors, 226

Mesotenon, vinculum as, 608

Metacarpal(s), 41f, 42f, 63–65, 63f, 64f, 65t

accessory bones of, 65

base of, bossing at, 661

heads of, 65

index finger, 64, 65t, 68–71, 69f, 131,

536

long finger, 64–65, 65t, 71–74, 72f, 133,

536

styloid process of, 642, 643f

mobility of, 536

muscle origins and insertions of,

112–113, 160

ring finger, 64–65, 65t, 74–44, 75f, 536

sesamoid bones of, 65

index finger, 71

small finger, 78

thumb, 68

small finger, 64–65, 65t, 77–79, 77f,

143, 536

styloid process of, 487, 487f, 642, 643f

thumb. See Thumb, metacarpal of

Metacarpal arcades, venous, 644, 644f, 645f

Metacarpal arches, basal, 48f, 255f,

265–266, 265f, 509

dorsal, 506–507, 507f

palmar, 508f

Metacarpal artery(ies)

dorsal, 253f, 550, 551f, 555

first, 266, 566

in index finger, 563f, 564, 566–567

in thumb, 563f

palmar, 238f, 249f, 265f, 553–555, 553f

first, 564, 565f, 566

in index finger, 562–563, 563f, 565f,

568

in thumb, 562–563, 563f, 565f, 568

in tissue transfer, 269–270

Metacarpal ligaments, transverse, 545, 604,

606f

superficial (natatory), 545, 595, 596f,

597, 597f, 598, 620, 620f, 622

Metacarpal veins, dorsal, 270, 271, 271f

Metacarpophalangeal joint(s), 81, 81f, 542,

543f–545f, 545, 545t

dislocation of, thumb, 627–628, 628f

extensor mechanisms at, 652

disruption of, 652, 653f

index finger, dislocation of, 628–630,

629f, 630f

innervation of, 573

lumbrical action on, 158–159, 158t, 589

skin creases at, 533

subluxation of, 221

surgical exposures for, 656, 657f

finger, 617, 619f

thumb, 615–617, 616f–618f

thumb, 85, 540–542, 541f, 542f

injury of, 679

surgical exposure for, 615–617,

616f–618f

ulnar collateral ligament disruption in,

688

Metacarpophalangeal ligament, injuries of,

627

Metaphyseal arches, palmar, 515–516, 516f

Metaphyseal branches, of digital arteries,

560–561, 561f

Metastasis, to humerus, blood supply and,

334

Mid-axial incision, in palm, 614, 614f

Mid-carpal joint, 494

anomalies and variations of, 527–528,

527f, 528f

ligaments of, 501–502, 501f

Middle finger test, for radial tunnel

syndrome, 478

Mid-palmar space, 604

“Mobile wad of three” muscle group, 408,

408f, 422, 422f, 423f, 461, 462f

Monteggia fracture, 35, 685

reverse (Galeazzi fracture), 36, 40, 679

Motor branches

of median nerve, recurrent. See Median

nerve, recurrent motor branch of

of radial nerve, 337f, 426, 426f, 427f,

429f, 455

of ulnar nerve, 201f, 206, 571f, 575,

576f–578f, 577, 578t, 579–581,

581f

deep, 201f, 210–212, 637–638, 638f

to ring finger, 206

MSCN. See Musculocutaneous nerve

Multangulum majus secundarium (os

trapezium secundarium), 60, 61, 63,

68, 71

Multangulum minus secundarium (os

trapezoideum secundarium), 59–61,

68, 71

Mummenthaler sign, 685–686

Muscle(s), 91–184

abductor digiti minimi, 155–156, 182t,

214, 583, 583f, 682

Subject Index 709

abductor indicis, 161–162, 587

abductor pollicis brevis. See Abductor

pollicis brevis muscle

abductor pollicis longus. See Abductor

pollicis longus muscle

abductor pollicis tertius, 146

accessories ad flexoram digiti minimi,

119

accessory. See specific muscles

actions and biomechanics of, 180t–183t

adductor pollicis, 154–155, 182t,

582–583, 582f

anconeus, 105–106, 180t, 461, 463f,

464f, 465

anconeus epitrochlearis, 124, 208, 405,

456

anconeus sextus, 106

of antecubital fossa, 422–423, 424f

architectural features of, 107t, 108f, 184t.

See also specific muscles

intrinsic, 150, 150t, 151f, 158t

wrist extensors and flexors, 113, 114t

of arm, 325–327, 326f, 328f. See also

Forearm, extensor, muscles of;

Forearm, flexor, muscles of; specific

muscles

biceps brachii. See Biceps brachii muscle

brachialis. See Brachialis muscle

brachiofascialis, of Wood, 103

brachioradialis. See Brachioradialis muscle

(supinator longus muscle)

brachioradialis brevis, 109, 455

capsularis brachialis, 103

compartments of, 183t

coracobrachialis, 96–98, 180t, 326, 326f,

327f, 338f, 362

coracobrachialis inferior, 362

coracobrachialis longus, 362

coracobrachialis minor, 97

deltoid. See Deltoid muscle

dorsoepitrochlearis, 105

epitrochleoanconeus, 124, 208

epitrochleocubital, 106

epitrochleoolecranonis anconeus, 124

epitrochleoolecranonis anconeus

epitrochlearis, 106

extensor atque abductor pollicis

accessorius, 146

extensor carpi radialis accessorius, 132

extensor carpi radialis brevis. See Extensor

carpi radialis brevis muscle

extensor carpi radialis intermedius, 132,

132f, 134, 484, 664, 664f

extensor carpi radialis longus. See

Extensor carpi radialis longus muscle

extensor carpi ulnaris. See Extensor carpi

ulnaris muscle

extensor digiti minimi. See Extensor digiti

minimi muscle

extensor digitorum brevis manus, 139,

140f, 141, 662–663, 663f

extensor digitorum communis. See

Extensor digitorum communis

muscle

extensor indicis et medii communis, 139,

140f, 484–485, 661–662, 662f

extensor indicis proprius, 141–142, 181t,

427, 428f, 465f, 466

extensor medii et annularis communis,

139

extensor medii proprius, 138t, 139, 140f,

484, 661–662, 661f

extensor pollicis brevis muscle. See

Extensor pollicis brevis

extensor pollicis longus, 148–149, 181t,

427, 428t, 465f, 466

extrinsic extensor, 590–592, 590f–592f

fascial spaces of, 183t

flexor carpi radialis. See Flexor carpi

radialis muscle

flexor carpi radialis brevis, 115, 134, 447,

448f, 456

flexor carpi ulnaris. See Flexor carpi

ulnaris muscle

flexor digiti minimi, 156, 182t, 214, 583,

583f

flexor digitorum profundus. See Flexor

digitorum profundus muscle

flexor digitorum profundus indicis, 127

flexor digitorum sublimis (flexor

digitorum superficialis muscle),

120–123, 180t

flexor digitorum superficialis. See Flexor

digitorum superficialis muscle

flexor indicis profundus, 127

flexor pollicis brevis, 152–153, 182t, 211,

582–583, 582f

flexor pollicis longus. See Flexor pollicis

longus muscle

of forearm. See also Forearm, extensor,

muscles of; Forearm, flexor, muscles

of

dorsal, 461–466

flexor, 416–423

Gantzer’s. See Gantzer’s muscle (accessory

flexor pollicis longus muscle)

of hand, 581–595

hypothenar. See Hypothenar muscles

infarction of, in compartment syndrome,

449–450

innervation of, 180t–183t

insertions of, 180t–183t. See also specific

muscles and bones

in hand, 112f–113f, 581–582

interosseous. See Interosseous muscle(s)

intrinsic. See Intrinsic muscle(s); specific

muscles

Langer’s, 186

latissimocondyloideus, 105

lumbrical. See Lumbrical muscles

“mobile wad of three” group, 408, 408f,

422, 422f, 423f, 461, 462f

omohyoid, 297, 299f

opponens digiti minimi, 156–157, 182t,

583f, 584

opponens pollicis, 153–154, 182t, 211,

582–583, 582f

origins of, 180t–183t. See also specific

muscles and bones

in hand, 112f–113f

palmaris bitendinous, 117

palmaris brevis, 155, 182t, 578f, 579,

583, 583f

palmaris brevis profundus, 638

palmaris longus. See Palmaris longus

muscle

palmaris longus inversus, 117, 118f

palmaris longus profundus, 117

palmaris profundus, 198–199, 447, 448f,

456

pectoralis major, 299f, 300f

pectoralis minor, 299f, 300f

platysma, 307

pronator quadratus, 129–130, 181t, 421,

421f

pronator teres. See Pronator teres muscle

sternocleidomastoid, 297, 298f

subanconeus, 104, 106

supinator. See Supinator muscle

supinator longus. See Brachioradialis

muscle

tensor ligamenti anularis anterior, 145

thenar, 159, 503f, 582–583, 582f. See

also specific muscles

transversus manum, 154

trapezius, 297, 298f

triceps brachii. See Triceps brachii muscle

ulnaris digiti minimi, 144

ulnaris digiti quinti, 144

vascular systems of. See specific muscles

Wood’s, 97

Musculocutaneous nerve, 299f

anomalies and variations of, 220, 223,

312, 314, 363

in antecubital fossa, 424f

in axilla and arm, 222, 329f, 336, 338f,

339f

in biceps brachii muscle innervation,

98–101

in brachialis innervation, 102–103

in brachial plexus, 300f, 301f, 304f,

306

injury of, 311–312

clinical correlations of, 223

in coracobrachialis muscle innervation,

96–98

course of, 187f

in forearm, 222–223

injury of, 311–312

710 Subject Index

Muscle(s) (contd.)

median nerve communication with, 340,

363

muscular branches of, 340t

origin of, 222

palsy of, 101

surgical exposures for, 312

variations of, 101

Myositis ossificans, of elbow, 405

N

Nail units, 654–656

blood supply of, 655–656, 655f

extensor tendon insertion and, 654f, 656

function of, 656

injury of, 655

innervation of, 656

nail bed (matrix), 654–655, 654f

nail fold, 654, 654f

nail plate, 654, 654f, 656

nomenclature of, 654, 654f

venous system of, 644f, 645, 655

Natatory cord, in Dupuytren’s contracture,

621f, 622

Natatory ligaments, 545, 595, 596f, 597,

597f, 598, 620, 620f, 622

Navicular. See Scaphoid

Naviculocapitate syndrome, 59

Neck, triangles of, 297, 298f, 299f

Necrosis, avascular. See Avascular necrosis

Neer classification

of distal clavicle fractures, 7

of impingement syndrome, 25

Nerve(s)

antebrachial cutaneous. See Antebrachial

cutaneous nerve

in antecubital fossa, 431, 432f

articular, 573

axillary. See Axillary nerve

brachial cutaneous. See Brachial

cutaneous nerve(s)

in brachial plexus. See Brachial plexus

in carpal tunnel, 196–197, 196t, 199,

574, 574t

in cubital tunnel, 205–206

cutaneous. See Cutaneous nerve(s)

digital. See Digital nerves

endings of, 225f, 226

Froment-Rauber, 219

in Guyon’s canal, 209–210, 577, 578t

of Henle, 201f, 455, 681, 569, 569f

intercostobrachial, 202f–203f, 224

intercostobrachial cutaneous, 325f

interosseous. See Interosseous nerve(s)

median. See Median nerve

median recurrent, 535f, 612f, 613

motor branches of. See Motor branches

musculocutaneous. See Musculocutaneous

nerve

nerves of, 571f–572f, 573, 612f, 613

pectoral, 305

phrenic, 299f, 300f, 301, 302f, 307

accessory, 302f

radial. See Radial nerve

scapular, 301

sensory branches of. See Radial nerve,

sensory branch of; Ulnar nerve,

sensory branch of

spinal, as brachial plexus roots, 300–301,

301f–303f, 303–304, 308f

subscapular, 305f, 306

suprascapular, 18, 302f, 304–305, 305f,

310

sympathetic fibers in

in anterior interosseous nerve, 188

in radial nerve, 218

in ulnar nerve, 206, 211, 579

thenar, 572f, 573–574, 574t

thoracic, 301, 301f, 305f

thoracodorsal, 301f, 305f, 306

ulnar. See Ulnar nerve

in ulnar tunnel, 209–210, 212–214, 213t

of Wrisberg, 223–224

Nerve block, of palmar cutaneous nerve

branch, 195

Nerve graft

lateral antebrachial cutaneous nerve as,

415–416, 444, 445f

medial antebrachial cutaneous nerve as,

321

Neural loop, of deep motor branch of ulnar

nerve, 637–638, 638f

Neuritis

of Parsonage-Turner, 194

radial, 480, 481f

Neuroma, of thumb, 672

Neurovascular bundle, of arm, 327–328,

329f–331f. See also specific arteries

and nerves

Nightstick fractures, 35

Notta’s node, 623

Nutrient artery

accessory, of profunda brachial artery,

246

of humerus, 332, 333f

Nutrient canal, of humerus, 23–24

Nutrient foramina

of radius, 29f

of ulna, 29f

O

Oblique communicating veins, 644f, 646

Oblique cord, of interosseus membrane,

410, 411f

Oblique dorsal artery of the distal ulna,

514, 516f

Oblique ligaments, of thumb, 538–540,

538t, 539f

Oblique retinacular ligament, 683–684,

590f–592f, 592

Olecranon, 367, 367f, 409f, 410

fractures of, 35

as landmark, 315, 316f–318f, 365, 366f,

461, 462f

muscle origins and insertions of, 34, 105

osteology of, 28, 30f, 31f

osteotomy of, 35, 376, 377f

Olecranon articula rete, 246

Olecranon fossa, 20f, 24, 319f, 366, 367f

Ollier’s phenomenon, 686

Omohyoid muscle, 297, 299f

Opponens digiti minimi muscle, 156–157,

182t, 583f, 584

Opponensplasty, for thumb paralysis,

152–154, 156

Opponens pollicis muscle, 153–154, 182t,

211, 582–583, 582f

Organelles, sensory, 225–226, 225f

Os acromiale, 9, 17

Osborne’s band, 416

ulnar nerve compression at, 391,

393–394, 394f

Os capitatum. See Capitate

Os capitatum secundarium, 57, 59, 71, 74,

77

Os carpometacarpale I (os praetrapezium),

61, 63

Os carpometacarpale II (multangulum

majus secundarium), 60, 61, 63

Os carpometacarpale III (os

parastyloideum), 57, 59, 68–69, 71,

74

Os carpometacarpale IV (os styloideum),

57, 59, 71, 74

Os carpometacarpale V (os capitatum

secundarium), 57, 59, 71, 74, 77

Os carpometacarpale VI (os gruberi), 57,

59, 71, 74, 77

Os carpometacarpale VII (os hamulare

basale), 55, 57

Os carpometacarpale VIII (os vesalianum

manus), 53, 55, 57, 77, 78

Os centrale, 42, 43f, 44, 49, 60, 61, 529

Os centrale dorsale, 42, 43f, 44, 49, 57, 59,

60, 61

Os centrale II (os epilunatum), 43f, 44, 50,

52, 57, 59

Os centrale III (os hypolunatum), 50, 52,

57, 59

Os centrale IV (os epitriquetrum), 50, 52,

53, 55, 57, 59

Os epilunatum, 43f, 44, 50, 52, 57, 59

Os epipyramis (os epitriquetrum), 50, 52,

53, 55, 57, 59

Os episcaphoid (os centrale), 42, 43f, 44,

49, 57, 59, 60, 61

Os epitrapezium, 43f, 44, 49–50, 61, 63

Os epitriquetrum, 50, 52, 53, 55, 57

Os gruberi, 57, 59, 71, 74, 77

Os hamulare basale, 55, 57

Os hamuli proprium, 55, 57, 74, 77

Subject Index 711

Os hypolunatum, 50, 52, 57, 59

Os hypotriquetrum, 50, 52, 53, 55, 57, 59

Os intermedium antebrachii (os

triangulare), 27, 50, 52, 53

Os lunatum. See Lunate

Os magnum. See Capitate

Os metacarpale III (os parastyloideum), 57,

59

Os metapisoid (os pisiforme secundarium),

27, 35, 53, 54

Os metastyloideum, 57, 59, 60, 61, 68, 71

Os multangulum minus. See Trapezoid

Os parascaphoid (os radiale externum), 36,

43f, 44, 49, 61, 63

Os parastyloideum, 57, 59, 68–69, 71, 74

Os paratrapezium, 61, 63

Os pisiforme secundarium, 27, 35, 53, 54

Os praetrapezium, 61, 63

Os radiale externum, 36, 43f, 44, 49, 61, 63

Os radiostyloideum, 36, 43f, 44, 49

Ossa metacarpalia I, 65–68, 67f

Ossa metacarpalia II (index finger

metacarpal), 64–65, 65t, 68–71, 69f

Ossa metacarpalia III (long finger

metacarpal), 64–65, 65t, 71–74,

72f, 133

Ossa metacarpalia V (small finger

metacarpal), 64–65, 65t, 77–79,

77f, 143

Ossification, heterotopic, of elbow, 405

Ossification centers. See also specific bone,

ossification centers of

appearance of, vs. age, 80t

Os styloideum, 57, 59, 71, 74

Os subcapitatum, 57, 59, 71, 74

Osteochondrosis, of humeral capitulum, 27

Osteonecrosis. See Avascular necrosis

Osteotomy

of humeral epicondyles, 380, 381f

of olecranon, 35, 376, 377f

Os trapezium secundarium, 60, 61, 63, 68,

71

Os trapezoideum. See Trapezoid

Os trapezoideum secundarium, 59–61, 63

Os triangulare, 27, 35, 50, 52, 53

Os triquetrum secundarium (os triangulare),

27, 50, 52, 53

Os ulnare externum, 53, 55, 57

Os ulnostyloideum, 27, 35

Os vesalianum manus, 53, 55, 57, 77, 78

Os vesalii (os vesalianum manus), 53, 55,

57, 77, 78

P

Pacinian corpuscles, 225–226, 225f

Palmar aponeurosis pulley, 596, 599–600,

600f

Palmar arches

deep, 238f, 267–268, 267f, 249f, 255f,

267f, 510, 550, 552, 553f–554f

branches of, 553, 553f

complete, 552, 554f

incomplete, 552, 554f

skin reference lines for, 535f

variations of, 268–269

of digital arteries, 566, 567f

superficial, 238f, 249f, 254–259, 255f,

256t, 508f, 550f, 557, 558f

branches of, 238f, 255f, 258–259, 557,

559, 559f

complete, 557, 558f

incomplete, 557, 558f

skin reference lines for, 535f

variants of, 255–257

transverse, 560–561, 561f

veins accompanying

deep, 275

superficial, 271, 272f

Palmar artery, superficial, 509, 509f

lesions of, 261

Palmar branch

of radial artery, 249f, 263, 267f

of radial nerve, 322f, 415f

Palmar carpal branch

of anterior interosseous artery, 249f

of radial artery, 263–264, 508f, 550f

of ulnar artery, 254

Palmar creases, 488f, 489, 489f, 533–534,

533f, 534f

Palmar cutaneous branch

of median nerve. See Median nerve,

palmar cutaneous branch of

of ulnar nerve, 201f, 206, 569, 569f

transverse, 569–570, 569f

variations in, 212

Palmar digital arteries, arches of, 566, 567f

Palmar fascia, 595–597, 596f, 597f, 619,

620f

Palmar interosseus muscle(s), 158t,

164–165, 183t

Palmaris bitendinous muscle, 117

Palmaris brevis muscle, 155, 182t, 578f,

579, 583, 583f

Palmaris brevis profundus muscle, 638

Palmaris longus inversus muscle, 117, 118f

Palmaris longus muscle, 416, 417f, 596f

absence of, 115–120, 180t

accessory slips of, 119

actions and biomechanics of, 116–117

anomalies and variations of, 117, 118f,

119, 213, 456

central belly, 119

clinical correlations of, 119–120

continuous muscle, 117, 119

continuous tendon, 119

digastric head of, 117, 118f

distal or reverse belly, 117, 118f

as donor muscle, 117, 120

gross anatomy of, 115–116

identification of, 422, 423f

innervation of, 116

intra-palmar accessory head of, 119

as landmark, 408, 408f

palmar cutaneous nerve branch in,

191–192

split or double belly, 117, 118f

substituting for digital flexors, 119

triple muscle bellies in, 119

vascularity of, 116

Palmaris longus profundus muscle, 117

Palmaris profundus muscle, 198–199

anomalies and variations of, 456

anterior interosseous nerve compression

at, 447, 448f

Palmar plates

of fingers, 542, 543f–544f, 546,

546f–547f

of interphalangeal joints, 546, 546f–547f

of thumb, 541

Palmar plexus (lymphatic vessels), 277

Palmar radiocarpal arch, 263–264

Palmar scaphoid branches, of radial artery,

264–265, 511

Palmar spaces, 604–605, 606f

Palmar ulnar-median communicating

branch of Berrettini, 198, 199

Palmar ulnar space, 604

Panner’s disease, 27

Papillar network, of nail unit blood supply,

655, 655f

Paralysis. See specific muscles and nerves

Paratenon, 609

Parona’s space, 605, 606f, 607, 686

Parsonage-Turner syndrome, 194

Patella cubiti, 105

PCBMN. See Median nerve, palmar

cutaneous branch of

Pectoral branch, of thoracoacromial artery,

241

Pectoral group of axillary lymph nodes, 280,

280f

Pectoralis major muscle, 299f, 300f

Pectoralis minor muscle, 299f, 300f

Pectoral nerves, 305

Perforating veins, of hand, 647

Peritendinitis crepitans (intersection

syndrome), 133, 134, 146–148,

480, 482f, 483

Perpendicular line, of ulna, 33

Phalanges, 79–86, 536

distal, 41f, 42f, 65t, 79, 79f, 83–85

arteries of, 655–656, 655f

muscle origins and insertions of,

125

nail unit and, 654f, 655f

ossification centers of, 43f

thumb, 86, 127–129

fractures of, Seymour’s, 688

joints of. See specific joints

middle, 41f, 42f, 65t, 79, 79f, 82–83

712 Subject Index

muscle origins and insertions of,

120–121

ossification centers of, 43f

muscle origins and insertions of

abductor pollicis brevis, 149–150

dorsal interosseous, 160, 587

extensor digitorum communis,

135–136, 136f, 137f

extensor pollicis brevis, 147

extensor pollicis longus, 148–149

flexor digitorum superficialis, 120–121

flexor pollicis longus, 127–129

proximal, 41f, 42f, 65t, 79–82, 79f, 80t,

81f

ossification centers of, 43f

surgical exposures for, 656, 657f

thumb, 85–86

thumb, 85–86

distal, muscle origins and insertions of,

127–129, 148–149

proximal, muscle origins and insertions

of, 147, 149–150

tubercles of, 84

tufts of, 84, 86

Phalen’s test, 686–687

Phrenic nerve, 299f, 300f, 301, 302f, 307

accessory, 302f

Piedmont (Galeazzi) fracture, 36, 40, 679

PIN. See Interosseous nerve(s), posterior

Pinch

dorsal interossei function in, 163

Froment’s sign in, 679

Kapandji’s test for, 683

PIP. See Interphalangeal joint(s), proximal

Pisiform, 41f, 42f, 54–55, 54f, 491f

as landmark, 408, 408f, 488, 488f, 532,

533f

ligaments of, 492

muscle origins and insertions of, 123

ossification centers of, 43f, 54

osteology of, 492

skin reference lines for, 535f

surgical exposures for, 522, 525f–526f, 527

vascularity of, 492, 507f, 508f, 512–513

Pisohamate ligament, 210, 494, 499f

Pisometacarpal ligament, 210

Pisotriquetral ligament, 492

Pitres-Testut sign, 687

Platysma muscle, 307

Plica, in wrist, 528

PL muscle. See Palmaris longus muscle

Pollicis artery, dorsal, 253f, 255f, 265f,

507f, 508f, 551f

Pollock’s sign, 687

Posterior interosseous nerve. See

Interosseous nerve(s), posterior

Posterior interosseous nerve syndrome,

477–478, 480

Posterior oblique ligament, of thumb, 538t,

539–540, 539f

Preiser’s disease, 49, 514

Prestyloid recess, of radiocarpal joint, 494

Pretendinous bands, 595, 596f, 620, 620f

Pretendinous cord, in Dupuytren’s

contracture, 621f

Princeps pollicis artery, 266, 267f, 562

absence of, 269

Process(es)

acromion. See Acromion

coracoid process. See Coracoid process

coronoid. See Coronoid process, of ulna

styloid. See Styloid process

supracondylar, of humerus, 26, 188

Profunda brachii. See Brachial artery, deep

(profunda)

Pronation, of forearm, muscles for, 407,

408f

Pronator quadratus muscle, 129–130, 181t,

421, 421f

Pronator quadratus sign, 687

Pronator ridge, of ulna, 33

Pronator syndrome, 111, 192–193, 445,

446f

persistent median artery in, 261

Pronator teres muscle, 110–111, 180t, 416,

417f

anomalies and variations of, 456

in antecubital fossa, 424f, 425f

anterior interosseous nerve compression

at, 447, 448f, 449

high origin of, 356, 361, 361f

identification of, 422, 423f

median nerve compression at, 192–193,

445, 446f

pronator quadratus working with, 129

Pseudoboutonniere deformity, 660

Pseudoulnar claw hand, 221

PT muscle. See Pronator teres muscle

Pulled elbow syndrome, 399

Pulley system, 599–602

annual, 543f

digital flexor sheaths in, 600–602, 600f

functional anatomy of, 598, 602, 604t

of interphalangeal joints, 546, 546f–547f

palmar aponeurosis as, 596, 599–600,

600f

rupture of, 624–625, 624f

of thumb, 602, 603f, 604t

of wrist, 599

Pulp arch, 567, 567f

Q

Quadrate ligament, 32f

Quadrilateral space syndrome, 244

R

Radial artery, 249f, 253f, 262–270

absence of, 268

accessory, 268

aneurysms of, 269

anomalies and variations of, 268–269,

457–458

in antecubital fossa, 423–424, 424f, 425f

in basal metacarpal arch, 265–266, 265f

branches of, 238f, 239f, 262t, 263–268,

265f, 267f

in carpal bone supply, 45–46, 46f–49f

clinical correlations of, 269–270

compression of, in Allen test, 260,

669–670

course of, 238f, 245f, 431, 434f

in deep palmar arch, 238f, 267–268, 267f

variations of, 268–269

distal division of, 248, 259

dominance of, 260–261

dorsal carpal branch of, 264, 265f

in dorsal intercarpal arch, 265–266, 265f

dorsal metacarpal branches of, 266,

269–270

in dorsal radiocarpal arch, 264, 265f

dorsal ridge of scaphoid artery, 264, 265f

emboli of, 269

first dorsal metacarpal artery of, 266

in flaps, 269, 457–458

in forearm, anomalies and variations of,

457–458

in forearm flaps, 269

gross anatomy of, 262–263, 262t

in hand, 549, 550f

high division of, 243, 244, 247

high origin of, 268, 363

index, 259, 266–267, 562

muscular branches, 263

origin of, in high division axillary

anomaly, 243

palmar carpal branch of, 263–264, 508f,

550f

in palmar intercarpal arch, 264

palmar radiocarpal branch of, 263–264

palmar scaphoid branches of, 264–265,

511

princeps pollicis artery of, 266, 267f

absence of, 269

recurrent, 238f, 239f, 263

in superficial arch, 256–257

superficial branch of

anomalous, 268

palmar, 238f, 249f, 263, 564, 565f

in thumb, 563f, 564, 565f, 567f

thrombosis of, 269

in trapezium vascularity, 62

in vascularized bone grafts, 269

at wrist, 265f, 507–509, 507f, 509f,

508f, 514–516, 516f–517f, 535f

Radial bursa, of flexor tendon sheath, 602,

603f

Radial collateral artery, 238f, 239f, 245f,

246, 330f, 331f, 369f, 370t

Radial collateral ligament, 372–374, 373f,

374f, 544f

Subject Index 713

injuries of, 626–627

protection of, in elbow surgery, 378

Radial deviation, of fingers, 545t

Radial fossa, 21f, 366, 367f

Radial index artery, 259, 266–267, 562

Radial lymph vessels, 277, 278

Radial marginal septum, of hand, 604,

606f

Radial nerve, 214–222

in anconeus innervation, 106

anomalies and variations of, 455

in antecubital fossa, 424, 424f

anterior interosseous branch of, posterior

interosseous nerve communication

with, 222

articular branches of, 573

in axilla and arm, 214–216, 215f, 215t,

329f, 334, 335f–337f

in brachial plexus, 299f, 301f, 306

branches of, 426, 427f, 428t

clinical correlations of, 334

compression of

in arm, 356

in brachioradialis variations, 110

in radial tunnel. See Radial tunnel

syndrome

cutaneous branches of, 202f–203f, 323f

distal division of, 334, 337f

division of, into motor and sensory

branches, 426, 427f

extensor carpi radialis brevis branch of,

427–429

fibrous arcades of, 429, 429f–430f

in forearm and hand, 216–222, 216t,

217t, 426–431, 427f, 428t,

429f–430f

anomalies and variations of, 218–220

clinical correlations of, 220–222

course of, 216–218

in Froment-Rauber anastomosis, 219

Froment-Rauber nerve and, 219

injury of, 355–356

in Holstein-Lewis fracture, 216

wrist extensors in, 220

lateral branches of, 334, 335f, 336f

medial branches of, 334, 335f–337f

motor branch of, 337f, 426, 426f, 427f,

429f

anomalies and variations of, 455

muscle innervation sequence of,

426–427, 428t

muscular branches of, 334, 335f–337f

neuritis of, at wrist, 480, 481f

origin of, 214

palmar branch of, 322f, 415f

palsy of, in humeral fracture, 26

posterior branches of, 334, 335f–337f

posterior interosseous branch of,

217–218, 217t

anterior interosseous nerve

communication with, 222

clinical correlations of, 220–221

evaluation of, 221

safe and unsafe internervous planes

and, 221

sensory branch of, 480, 481f, 482f

anomalies and variations of, 455

course of, 429, 429f, 430f

dorsal, 573

origin of, 426, 426f, 427f

superficial branch of, 216–217, 216t,

322f, 323f, 415f

anomalies and variations of, 219–220

injury of, 222

neuritis of, 690

supinator branch of, 429

surgical exposures for, 355–356,

467–468, 467f–469f

anterolateral, 341, 343, 345, 345f,

346f

medial, 346–347, 347f–349f, 351

posterior, 351–353, 350f–353f

sympathetic fibers in, 218

in triceps innervation, 104

Radial notch, of ulna, 29–31, 29f, 31f–33f,

367, 367f

Radial recurrent artery, 249f, 255f, 330f,

368f, 369f, 370t, 508f, 510

in antecubital fossa, 423, 424f, 425f

radial nerve compression by, 478, 479f

Radial sulcus, 20f, 22f, 23, 24

Radial tunnel syndrome, 220, 477–480

anatomy of, 477

compression sites in, 478, 480–481, 479f

diagnosis of, 478

vs. lateral epicondylitis, 388

surgical exposures for, 469, 470f

symptoms of, 477–478

tests for, 478

Radial veins, 275–276

palmar, 644f

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