Download - Bab 6 Hand
Topographic Anatomy
Osteology
Radiology
Trauma
Tendons
Joints
Other Structures
Minor Procedures
History
Physical Exam
Origins and lnsertions
Muscles
Nerves
Arteries
Disorders
Pediatric Disorders
Surgical Approaches
Hand . TOPOGRAPHIC ANATOMY
Common namesof digits
Anterior view
ThumblndexMiddleRingLittle
Flexor carpiradi al is
Thenar eminence
Radial longitudinalPalmaris longustendon
Flexor digitorumsuperficialis tendons
lexor carpi ulnaris tendon
em tnence
palmar crease
imal digital crease
digital creasemetacarpophalangealjoint
Distal digital crease
Extensor pollicis Anatomicsnuff boxlongus tendon
Site of thumb
ioint
metacarpophalangealjoinl
Extensortendon
interphalangeal (PlP) joinl
te of distalinterphalangeal (DlP) joint
€(4"d-
Posterior view
Extensor digitorum tendons
of proximal
Palmaris longus tendon Not present in all people. Can be used for tendon grafts,
Anatomic snuffbox Site of scaphoid. Tenderness can indicate a scaphoid fracture.
Thumb carpometacarpal joint Common site 0f arthritis and source 0f radial hand pain.
Thenar eminence Atrophy can indicate median nerve compression (e.9., carpal tunnel syndrome).
Hypothenar eminence Atrophy can indicate ulnar nerve compression (e.9., ulnar or cubital tunnel syndrome)
Proximal palmar crease Approximate location of the superficial palmar arch of the palm.
Distal palmar crease Site of metacarpophalangeal joints on volar side of hand.
I84 NETTER'S CONCISE ORTHOPAEDIC ANATOMY
fscaphoidCarpal / andbones*/ Tubercle
,/ Trapeziu6
-/ rubercle/( Iraoezoicl/,
nquetrum.Pisiform
-Capitate
-Hamate ar\Hook\8"r" I\Shafrs !,,Head )
Zt:fsj
fuit::;)fTjr- base
Kil{i
OSTEOTOGY o Hond
Right hand:anterior (palmar) view
Sesamoid[6ns5-
Right hand:posterior (dorsal) view
NETTER'S CONCISE ORTHOPAEDIC ANATOMY I85
X-ray, hand
Hond . RADroLocY
D istalIN
joint (DlP)
Proximalinterphalangealjoint (PlP)
Metacarpo-phalangealjoint
Distalphalanx(P3)
Iuft
phalanx Index
lP2)
phalanx(P1)
Disral
Thumbinterphalangealjoint (lP)
D ista I
phalanx(P3)
Middlephalanx\P2)
Proximalphalanx(Pl )
Lateral x-ray, finger
X-ray, hand X-ray, finger
T86 NETTER,S CONCISE ORTHOPAEDIC ANATOMY
TRAUMA o Hond
Metacarpal Fractures
Transverse fractures of metacarpal shaft usuallyangulated dorsally by pull of interosseous muscles
Oblique fractures tend to shorten androtate metacarpal, particularly in index
ln fractures of metacarpal neck, volar cortex often and little fingers because metacarpalscomminuted, resulting in marked instability after of middle and ring fingers are stabilizedreduction, which often necessitates pinning by deep transverse metacarpal ligaments
Fracture of Base of Metacarpals of Thumb
I st metacarpal
Bone
Trapezium
Abductor pollicislongus tendon
4fNType I (Bennett fracture). lntraarticular fracturewith proximal and radial dislocation of l st meta-carpal. Triangular bone fragment sheared off
Fracture of Proximal Phalanx
Type ll (Rolando fracture).lntraarticular fracture withY-shaped configuration
ffiffiReduction of fractures of phalanges or metacarpals requires correct rotational as well as longitudinalaliSnment. ln normal hand, tips of flexed fingers point toward tuberosity of scaphoid, as in hand at left.
. Common in adults, usually a fall
or punching mechanjsm. 5th MC most common (boxer fx). Thumb MC base fractures: dis-
placed, intraarticular fracturesproblematic
" Bennett's fx: APL deforms fx. Rolando's fx: can lead to DJD
. 4th & sth l\40s can toleratesome angulation, 2nd & 3rdcannot
Hx: Trauma, pain, swell-ing,+/- deformity
PE: Swelling, tenderness,
Check for rotational de-formity, Check neurovas-cular integrity.
XR: Hand. Evaluate for an-gulation & shonening
CT: Useful to evaluate lornonunion of fracture
By location:. Head. Neck (most common). Shaft (transverse, spiral). Base
" Thumb MCo Bennett: volar lip fx
" Rolando: commi-nuted
. Small finger lVlC:
"Baby Bennett"
. Nondisplaced: cast
. Displaced: reduce
" Stable: cast. Unstable: CR-PCP
VS, ORIF
" Shortened:0RlF. lntraarticular
" Head:oRlF. Thumb base:
. Bennett:
CR-PCPo Rolando: oRlF
NFITER,S CONCISE ORTHOPAEDIC ANATOMY T87
Hond . aAUMA
iij.i
i1
'1+.
iii'
T
a
t1i
::''li'rtiit
rffim:J affi,q*# r
lntraarticular condyle fractures.
Fractures of distal phalanx
@%eTypes of fractures.A. LongitudinalB. Nondisplaced transverseC. Angulated transverseD. Comminuted
Phalangeal Fractures
lntraarticular phalangeal baseftacture. lntraarticular fracturesof phalanx that are non-displaced and stable maybe treated with buddytaping, careful observation,and early active exercise.
4{ffi4't'/
Extraarticular oblique shaft(diaphysis) fracture.
Extension block splint useful for fracture dislocation of proximal
. Common injury
. l\ilechanism: jamming, crush,
or tlvisting. Distal phalanx most common. Stitfness is common prob-
lem; early motion and occu-pational therapy needed forbest results
. lntraarticular fractures canlead to early osteoarthritis
. Nail bed injury common W/
tuft (distal phalanx) tx
Hx: Trauma, pain,
swelling, +/- deformityPE: Swelling, tenderness,
Check for rotational de-
formity. Check neurovas-
cular integrity.
XR: Hand. Evaluate forangulation & shoftening
CT: Useful to evaluate fornonunion of fracture
Description:. lntra- vs extraartrcular. Displaced/
nondisplaced. Transverse, spiral,
oblique
Location:. Condyle. Neck. ShafYdiaphysis. Base. Tuft
. Extraarticular:
" Stable: buddy tape/splint
" Unstable: CR-PCP vs
ORIF. lntraarticular: oRlF. l\4iddle phalanx volar
base fx:. Stable: extension block
splint
" tinstable: 0RlF. Tuft fx: inigate wound,
repair nail bed asneeded, splint fxldiqit
r88 NF|TER'S CONCISE ORTHOPAEDIC ANATOMY
Gamekeeper's thumb
A. Tendon torn fromits insertion. B. Bonefragment avulsed withtendon. ln A and B
there is a 40"- 45'flexion deformityand loss of activeextension
Ruptured ulnarcollateral ligamentof metacarpopha-langeal joint ofthumb
Flexor digitorum profundus tendon may be torn directly fromdistal phalanx or may avulse small or large bone fragment.
TRAUMA O Hond
Mallet finger
Splinted Mallet Finger
Adductor pollicis m.andaponeurosis (cut)
4w
. Rupture of extensor tendon
from distal phalanx. Soft tissue or bony form. l\,4ech: jamming finger
Hx: "Jammed" finger;pain, DIPJ deformity
PE: Extensor lag at DIPJ;
inability to actively ex-tend DIPJ
XR: Hand series. Look forbony avulsion (EDC) tx
from dorsal base of P3
in bony form of injury
i, DIPJ extension splint,
6wk for most injuries
2, Bony mallet with DIPJ
subluxation: considerPCP vs OR|F
. FDP tendon rupture from P3
. l\4ech: forced extension
against a flexed finger. Tendon retracts variably
Hx: Forced DIPJ exten-sion, injury; pain
PE: lnability to flex DIPJ
(-profundus test)
XR: Hand series. Look foravulsion fracture from
volar base of P3. lVay
be retracted to finger/palm.
Leddy classif ication: Type:. 1: to palm. Early repair. 2: to PIPJ. Repair <6wk. 3: bony to 44: 0RlF
;aiii:itrilli,ii:,i:i,l. Thumb IMCP joint proper ul
nar collateral ligament injury. l\4ech: forced radial deviation. 0ften a ski pole injury
Hx: Pain, decreased grip
PE: Pain & laxity ofIMCPJ at 30' of flexion,+/- palpable mass
$tenor lesion)
XR: Hand; r/o avulslon tx
Stress Fluoro: Can com-pare side to side asym,
MR: lf diagnosis is un-clear
. Incomplete tear (sprain)
or no Stenor lesion:
splint 4-6wk. Complete tear or Stenor
lesion: primary repair
NETTER,S CONCISE ORTHOPAEDIC ANATOMY I89
Hond . TENDoNS
I DIP
ll Middleilt PtP
Flexor zones of hand lV Proximal phalanx
Vlll Distal forearm
Extensor zones of hand
I-l lP joint
T-ll Proximal phalanx
I-lll MP joinl
-lV Metacarpal
T-V CMC joint radial styloid
JclrNA"cRA\-"ao
VI
Vll Dorsal retinaculum
Distal to FDS
insertionSingle tendon (FDP) injury. Primary repair. DIPJ contracture results if tendon short-
ened >1cm. Quadriga effect can also result
il Finger flexor
retinaculum
"No man's land," Both tendons(FDs, FDP) require early repair (within 7 days) and mo-bilization. Lacerations may be at different locaiions on each tendon and away fromskin laceration. Preserve A2 & A4 pulleys during repair
ilt Palm Primary repair. Arterial arch & median nerve injuries common.
IV Carpal tunnel Must release & repair the transverse carpal ligament during tendon repair
Wrist & forearm Primary repair (+ any neurovascular injury), Results are usually favorable.
Thumb I Distal to FPL
insertion
Primary tendon repair. Rerupture rate is high.
Thumb ll Thumb flexor
retinaculumPrimary tendon repair. Preserve either A.1 or oblique pulley
Thumb lll Thenar eminence Do not operate in this zone. Recurrent motor branch is at risk of injury,
DIP joint "Mallet finger." Splint rn extension for 6 wk continuously.
il Middle phalanx Complete lacerations: primary repair and exiension splint.
ilt PIP joint Central slip injury. Splint in extension for 6 wk. lf triangular ligament is also disrupted,lateral bands migrate volarly, resulting in "boutonniere finger"
ru Proximal phalanx Primary repair of tendon (and lateral bands if needed), then extension splint
MCP joint often from "fight bite." Repair tendon and sagittal bands as needed
VI l\4etacarpal Primary repair and early mobilization/dynamic splinting.
vil Wrisl Retinaculum likely injured. Primary tendon repair, early mobilization.
vil Distal forearm At musculotendinous jxn. Primary repair of tendinous tissue & immobilize
IX Proximal forearm 0ften muscle injury Neurovascular injury high. Repair muscle & immobilize,
T90 NETTER,S CONCISE ORTHOPAEDIC ANATOMY
Tendons of flexor digitorumsuperficial is
and profundusmuscles
(Synovial) tendinous
Common palmar digital
Proper palmar digital arteries and nerves
Annular and cruciform parts of fibrousover (synovial) flexor tendon sheaths
plates (palmar ligaments)
Superficial palmarbranch of radialartery and recurrentbranch of mediannerve to thenarmuscles
UInar arteryand nerve
Common palmardigital branchesof median nerve (cut)
muscles
sheath (u lnarbursa)
th finger(synovial)tendinous sheath
profundus tendon
l{ffii.l'/C//dda,A
NETTER'S CONCISE ORTHOPAEDIC ANATOMY I9I
Hond . lotNTs
Posterior (dorsal) view
Dorsal carpometacarpal I
Dorsal metacarpal I
Capitate
Trapezium
Capsule of 1 st carpo-metacarpal joint
Trapezoid
t{ffi4{/
r92 NETTER'S CONCISF ORTHOPAEDIC ANATOMY
Anterior (palmar) view
Trapezium
lotNnt o Hond
Pisiform
Hook of hamate
Palmar carpomelacarpal ligaments
Palmar metacarpal ligaments
transversemetacarpal ligaments
plates(palmar lig,aments)
';
lexor digitorum profundus tendons
Joint.uptul"\.
Collateral liSaments
Flexor digitorum /superf icial is tendons (cuf)
4{tr
Itllffitfs I
rlclilEtl trnHffiilS ..,.,.::
. Diarthrodial joint. Motion: primarV = flexion & extension; qecondary = r0tation, adduction, abduction
Capsule Surrounds joint Secondary stabilizer dorsally Taut in {lexion
Center ol metacarpal head topalmar Proximal Phalanx
Primary stabilizer. Taut in flexlon, test in 30' flexion
Ulnar Collateral injured in "gamekeeper's/skier s" thumb
Accessory collateral Palmar to proper collateral lig. Taut in extension Test integrity in extension'
Primary stabilizer in extension Laxity in extension indi-
catesiniury t0 volar plate (+/- accessory collateral lig )Volar (palmar) plate Palmar metacarpal head to pal-
mar proximal phalanx base
. Diarthrodialjoint. Molion: primary = flexion & extenliol
. Asymmetry of metaearpafhead & collateral ligamenlori
0-90"); secondary : radial & ulnar deviation
rssult in 'tam effect" (tight in flexion, lcj:ose in extension)
Capsule Sunounds joinl Secondary stabilizer; synovial reflections volar & dorsal
Proper collateral Dorsal MC head to palmar P1 Primary stabilizer; tight in flexion, loose in extenslon
Accessory collateral palmar MC head to volar plate Palmar to proper collaterals; stabilizes the volar plate
volar (palmar) plate Palmar MC head to palmar P1 Limits extension; volar suppon
base
Between adlacent metacarpal
bases and MCPJ volar Plates
lnterconnects the volar plates, MCPJs, and metacarpals.
Can prevent shortening oJ isolated metacarpal fracturesDeep transverse(inte0metacarPal
NETTER,S CONCISE ORTHOPAEDIC ANATOMY I95
Hond . lotNTs
Flexor digitorumprofundus (FDP)
tendon
Volar plate of PIPJ
Flexor digitorumsuperficialis (FDS)
tendon
Proximalphalanr (P1 )
Extensor tendon
Cleland's lig..
Lateral digital sheet
Neurovascular bundleDigital a.
Digital n.
Crayson's
Accessorycol Iateral
Proper collateral Iigamenl
Palmarsurface Proximal
,Dista I
/lnterpha langea I
- / rotet loint
F<,;:: Distal
Note: Ligaments of "'b * :i
metar arpophalargeal . 'r. " t'
and interphalangeil ' ' li€ *-
joints are similar -# " '
ln flexion: medial view
Phalangesln extension:medial view Volar (palmar Iigament)
Accessory collateral
Metacarpophalangeal (MP) joint
31i,,,u".n \
J L,ffi^.1'/JOHtrA.CRAt.-ao
Proximal interphalangeal
ioint
{'=* r'i4f* .***+*'tiEf'vot^,
ptut",
PBOXIMAT INT.FRPHATAI\IGEITL
Capsule Sunounds joint Weak stabilizer esp. dorsally (central slip adds most suoport)
Proper collateral Center of Pl head to volar P2 Primary stabilizer to deviation, Constant tension through ROM
Accessory collateral Volar proximal phalanx head
to volar plate (not bone)
Origin volar to axis of rotalion: tight in ext., loose in flexionThis can result in a contracture (do not immobilize in flexion)
Volar (palmar)
plateVolar middle phalanx to volar
proximal phalanx (via check-rein ligaments)
Primary restraint t0 hyperextension. Firm distal attachment,looser proximal attachment (more prone to injury).
Checkrein ligaments Often contract after iniury: contracture
OTHER IT{IERPHALAJ{GEAL
Capsule Surrounds joints Weak stabilizer
Proper collateral B/w adjacent phalanges Similar io PIPJ, constant tension, no "cam effect"
Accessory collateral Volar to collateral ligaments Similar to PIPJ, less prone to contracture than PIPJ
Volar (palmar) Volarly b/w phalanges Primary restraint t0 hyperextension; can be injuredplate
OTHER STRUCTURES
Grayson's ligament From flexor sheath to skin; volar
to neurovascular bundle
Stabilizes skin & neurovascular bundlelnvolved in Dupuytren's disease/nodules
Cleland's ligament From periosteum to skin Stabilizes skin during flexion/extension; dorsal to NV bundle
I94 NEITER,S CONCISE ORTHOPAEDIC ANATOMY
lnsertion of small deep slip of extensor tendonto proximal phalanx and joint capsule
Extensor expansion (hood)
Sagittal band
Attachment of interosseous m.to base of proximal phalanxand joint capsule
, :! :::|N
,gi#
Collateral lig.
Lumbrical m
Note: Black arrows indicatepull of long extensor tendon;red arrows indicate pullof interosseous andlumbrical muscles; dotsindicate axis ofrotation of joints.
IOINTS r Hond;
lnterosseous mmVolar plate(palmar ligament)
Flexor digitorumtendon (cut,
Conjoined lateral
Finger in flexion:lateral view
Terminal extensortendon insertion
lateral ligs
Flexor digitorumprofundus tendon (cut)
plate(palmar ligament)
6ry&4
lnsertion of;;;;;#;il; /+Central band rlrp/ " I
Metacaruophalangeal Joinl
Flexion lnterosseous muscles lnsert on proximal phalanx and lateral band (volar torotation axis)
Lumbricals lnserts on radial lateral band (volar to axis 0f rotationof t\itcPJ)
Sagittal bands insert on volar plate, creating a "lasso" aroundproximal phalanx base and extend joint through the lasso.
EDC has minimal attachment to Pl (which does not extendthe joint) but extends joints via the sagittal bands,
Proximal lntenhalangeal Joint
Flexion Flexor digitorum superficialis Primary PIPJ flexor via insertion on middle phalanx volar(FDS) base
Flexor digitorum profundus Secondary PIPJ flexor(FDP)
EDC via the central slip (band)
Lumbricals via lateral bandsCentral slip of EDC inserts on dorsal P2 base to extend PIPJ
Has attachment to radial lateral band (dorsal to rotation axis)
Distal Interphalangeal Joint
Flexor digitorum profundus
(FDP)
Tendon attaches at P3 volar base, pulls through tendonsheath
EDC via terminal extensortendon
0blique retinacular ligament(0RL)
Lateral bands converge at terminal insertion on dorsalP3 base
Links PIPJ & DIPJ extension; extends DIPJ as PIPJ is
extended
NETTER'S CONCISE ORTHOPAEDIC ANATOMY I95
Hond . orHER srRucruREs
lnsertion of central slip of extensortendon to base of middle phalanx
Triangular (aponeurosis)Iigament
Posterior(dorsal)view
Conjoined
Lateralbands
Extensorexpansion
Sagittalbands
lateral bands
Lateral slips o{long extensor
extensor tendon
lnterosseous muscles
Metacarpal bone
of interosseoustendon passes to baseof proximal phalanrand joint capsule
x$%o**tendon slip to
tendon to lateral bands lateral band muscle
Central Oblique Extensor expansion (hood)
Lateral Sagiftal bands Long extensor tendonlnsertion of extenso, tundon-
Iut"tul b"nd'
to base of middle phalanx rp
lnsertion of terminal extensortendon to base of distal phalanx
Finger inextension:lateral view
;*:;r;;-- \Lumbrical muscle
Flexor digitorum profundus tendon
Flexor digitorum superf icialis tendon
bone
muscles
. Dorsal ExtensorAponeurosis (also called dorsal expansion, dorsal hood, extensor hood)
lnserts on volar plate (Pl); extensor tendon(EDC) glides under it
Extends MCPJ via "lasso" around Pl base;
radial sagittal bands are weaker, may rupture
" Oblique fibers Covers |\4CPJ and base of proximal phalanx Holds EDC centered over MCPJ
Volar to MCPJ axis: flexes MCPJ
Dorsal to PIPJ axis: extends PIPJ
Lateral hood libers join tendinous portion ofinterossei/lumbricals to form lateral bands
' Extrinsic ExtensorTendon (EDC) glides underthe dorsal hood (to extend MCP) before trifurcating at prox. phalanx
. Lateral slip EDC trifurcates over Pl giving two lateral slips These slips conjoin with lateral bands
' Central slip Central slip oJ trifurcation; inserts base of P2 Extends PIPJ; torn in boutonniere injury
. Terminal extensor Confluence o1 two conjoined lateral bands on Extends DIPJ via insertion on dorsal base oltendon dorsal base of distal phalanx (P3) P3; avulsed in mallet finger injury
Confluence o{ EDC lateral slips and lateralbands from extensor aponeurosis
Both join distally to make terminal extensortendon
. Conjoined lateral
band
. Transverse retinacular From PIPJ volar plate and flexor sheath toligamenis both conjoined lateral bands
Prevents conjoined lateral band dorsal sub-luxation during PIPJ extension
Transverse bands over P2, connects bothconjoined lateral bands and terminal iendon
Prevents lateral band volar subluxation in
PIPJ flexion; torn in boutonniere injury
. Triangular ligament(aponeurosis)
' 0blique retinacular From volar Pl to dorsal P3/terminal tendon Extends DIPJ when PIPJ is extendedligament (ORL)
Tendinous connections between ECD ten-dons to adjacent fingers proximal to MCPJ
Prevents full extension of finger when adja-cent digit is flexed (see page 1 55)
196 NETTER'S CONCISE ORTHOPAEDIC ANATOMY
Tendinous sheathof flexor pollicislongus (radial bursa)
Common flexorsheath (ulnar bursa)
fhenar space
Midpalmarspace
Lumbrical(in fascialsheaths)
Tendinous sheath offlexor pollicis longus(radial bursa)
OTHER STRUCTURES O HONd
Commonflexor sheath(ulnar bursa)
Flexor digitorumsuperficialis tendons
flexor sheath(ulnar bursa) (opened)
Lumbrical muscles infascial sheaths
Midpalmar space(deep to flexor tendonsand lumbrical muscles)
Fibrous and synovial (tendon)sheaths of finger (openea)
Flexor digitorum superfi cialistendon (FDS)
Flexor digitorum profundustendon (FPS)
Flexor pollicis longus ten-don in tendon sheath(radial bursa)
pollicis
Flexor digitorumprofundustendons
Tendinoussheath of flexorpollicis longus(radial
Synovial tendonsheaths of fingers
Fascia of adductor pollicis
Thenarspace -..'.-(deep to flexor tendonand lst lumbrical muscle)
(Synovial) tendinoussheath of finger
Lumbrical muscles in fascialsheaths (cut and reflected)
g
]ilffiLl."
Midpalmar
Palmar
Common palmar digitalartery and nerue
Lumbrical musclein its fascial
Flexor tendons to 5thdigit in common flexorsheath (ulnar
Hypothenar musc
Dorsal interosseous
Prolundus and superficiali' ilexor tendons to 3rd digitbetrveen midpalmar and thenar spaces
space
longus tendon
pollicis muscle
Palmar interosseous fascia
Palmar interosseorrs mrrscles
Dorsal interosseous muscles
xtensor lendons
NETTER'S CONCISE ORTHOPAEDIC ANATOMY T97
Hond . OTHER STRUCTURES
Nail matrix
Sagittal section(germinal
Nail
Eponychium (cutic
LunulaNa il he.l
-(sterile matrir)
Body of nail
Distal phalanx
Epiphysis
I Nerves Arteries Septa I
membrane
Articular cartilage Extensor digitorum tendon
Middle phalanx
digitorumsuperficialis tendr
Fibrous tendonsheath finger
al (flexor tendon) sheathfinger
digitorum profundus tendon
Palmar ligament (plate)
Body of nail
Nail bed
Distal phalanx
Fibrous septa and areolartissue in anteriorclosed space (pulp)
Dorsal digital artery and nerye
palmar digital artery
Distal anterior closed space (pulp) Articular cavity
Cross sectionthrough distalphalanx
Dorsal branches of proper palmardigital arteries and nerves to dorsumof middle and terminal phalanges
Arteries and nerves
4{Y;Nutrient branch to epiphysis
Nutrient branches to metaphysii Proper palmar digital artery and nerue
T98 NFTTER,S CONCISE ORTHOPAEDIC ANATOMY
Thumb CMC lnjection Digital Block Digital block, bothsides of base offinger
Flexor Sheath lnjection
3i:l.i1li:*.*:*i:i:.Si1,*i itf.lE t.,i_1;:*i..1:::i*
1. Ask patient about allergies
2. Palpate thumb CMC joint on volar radial aspect
3. Prepare skin over CMC joint (iodine/antiseptic soap)
4. Anesthetize skin locally (quarter size spot)
5. Palpate base of thumb l\4C, pull axial distraction 0n thumb with slight flexion to open joint. Use 22 gauge or smallerneedle, and insert into joint (if available use an image intensifier to confirm needle is in joint). Aspirate t0 ensure nee-dle is not in a vessel. lnject 1 -2 ml of 1:.1 local (without epinephrine) /corticosteroid preparation into CMC joint. fhefluid should flow easily if needle is in joint)
6, Dress injection site
1. Ask patient about allergies
2. Palpate the flexor tendon at ihe distal palmar crease over metacarpal head/Al pulley.
3. Prepare skin over palm (iodine/antiseptic soap)4. lnsert 25 gauge needle into flexor tendon at the level of the distal palmar crease. Withdraw needle very slightly so
that it is just outside tendon, but inside sheath. lnject 2-3ml of local anesthetic without epinephrine. (Add corticoste-roid if injecting for trigger finger).
5. Dress injection site
1. Prepare skin over dorsal proximal finger web space (iodine/antiseptic soap)
2. lnsert 25 gauge needle between metacarpal necks (metacarpal block) or on eiiher side of proximal phalanx (digital
block) in digital web space. Aspirate to ensure that needle is not in a vessel. lnject l -2ml of local anesthetic (without
epinephrine) on both sides of the bones. Consider injecting local anesthetic dorsally over the bone as well,3, Care should be taken not to inject too much fluid into the closed space of the proximal digit.4, Dress injection site
NETTER,S CONCISE ORTHOPAEDIC ANATOMY I99
Hond . HtsroRY
Fractures and dislocations of thumb
tnjury to proximal phalanx ormetacarpophalangeal joint of thumbcaused by fall with outstretchedhand on ski pole
Fight bite
Penetration ofmetacarpophalangealjoint by tooth in fist fight
Boxer fracture
Fractures of metacarpalneck commonly resultfrom end-on blow of fist.Often called street-fighteror boxer fractures
Mallet finger
Usually caused by direct blow on extended distalphalanx, as in baseball, volleyball
n
ft{r
1. Hand dominance Right or Ieft Dominant hand injured more often
2. Age Young Trauma, infectionMiddleage-elderly Arthritis,nerveentrapments
3. Pain
a. onset
b. Location
Trauma, infection
ArthritisArthritis (0A) especially in womenArthritis (osteoarthritis, rheumatoid)Purulent tenosynovitis (+ Kanavel signs)
Acute
Chronic
CMC (thumb)
Joints (MCPS, lPs)
Volar (fingers)
4. Stiffness ln AM, "catching" Rheumatoid arthritisCatching/clicking Trigger finger
After trauma
No traumalnfection (e.9., purulent tenosynovitis, felon, paronychia)
Trigger finger, arthritides, gout, tendinitis
Ganglion, Dupuytren's contracture, giani cell tumor
Fall, sports injury
0pen woundFracture, dislocation, tendon avulsion, ligament injurylnfection
8. Activity Sports, mechanical Trauma (e.9., fracture, dislocation, tendon or ligament injury)
9. Neurologic symptoms Pain, numbness, tingling
Weakness
Nerve entrapment (e.9., carpal tunnel), thoracic ouflelsyndrome, radiculopathy (cervical)
Nerve entrapment (usually in wrist or more proximal)
10' Historyof arthritides Multiple jointsinvolved Rheumatoidarthritis,Reitefssyndrome,etc.
2OO NETTER,S CONCTSE ORTHOPAEDIC ANATOMY
Rheumatoid arthritisBoutonniere deformity of indexfinger with swan-neck deformityof other fingers
PHYSICAL EXAM . Hond
OsteoarthritisHeberden's nodes seen in index and middle fingerdistal interphalangeal joints. Bouchards nodes seenin proximal interphlangeal joints of the ring andsmallfinger
Rotation displacement of ringfinger. All fingers should pointtoward scaphoid when clenched
Median nerve compressionAtrophy of thenar musclesdue to compression of mediannerve
Gross deformity Ulnar drift/swan neck, boutonniere Rheumatoid arthritis
Rotational or angular deformity Fraciure
Finger position Flexion Dupuytren's contracture, purulent tenosynovitis
Rotation of digit Fracture (acute), fracture malunion
Skin, hair, nail changes Cool, hairless, spoon, etc Neurovascular disorders: Raynaud's, diabetes,nerve rnlury
0steoarthritis: Heberden's nodes (at DlPs: #1),
Bouchard's nodes (at PlPs)
Rheumatoid arthritis
Purulent tenosynovitis
DIPS
PlPs
MCPs
Fusiform shape finger
Thenar eminence
Hypothenar eminence/intrinsics
Median nerve injury, CTS, CB/|1 pathology
Ulnar nerve injury (e.9., cubital tunnel syndrome)
NETTER'S CONCISE ORIHOPAEDIC ANATOMY 2OI
Hond . PHYSIcAL ExAM
of the fingers
Flexion contracture of 4th and 5th fingers (most common).Dimpling and puckering of skin. Palpable fascial nodulesnear flexion crease of palm at base of involved fingerswith cordlike formations extending to proximal palm
Patient unable to extend affected finger. lt can beextended passively, and extension occurs with distinctand painful snapping action. Circle indicates point oftenderness where nodular enlargement of tendons andsheath is usually palpable
Purulent tenosynovitis.Four cardinal signs of Kanavel
4. Tenderness along tendon sheath
Stenosing tenosynovitis(trigger finger)
lnfections
ffiffigffiw@ilwffitWParonychia 4 ff87
4 t'/Felon
Warm, red
Cool, dryInfection
Neurovascular compromise
Metacarpals Each along its length Tenderness may indlcate fracture
Phalanges and finger joints Each separately Tenderness: f racture, arthritisSwelling: arthritis
Thenar eminenceHypothenar eminencePalm (palmar fascia)
Flexor tendons: along volar fingerAII aspects of finger tip
Wasting indicates medjan nerve injuryWasting indicates ulnar nerve injuryNodules: Dupuy,tren s contracturei snapping41 pulley with finger extension: trigger finger
Tenderness suggests purulent tenosynovitisTenderness: paronychia or felon
202 NETTER'S CONCISE ORTHOPAEDIC ANATOMY
PHYSICAT ExAM . Hond
J6FINA.€RAK,J^6I
Normal thumb
Ulnardeviation
Normal finger flexion is
composite of flexion ofMP, PlP, and DIP jointsand allows fingertip totouch distal palmar crease
Range of thumb opposition
opposition is compositeof movemens of CMC,MP, and lP joints.Normal range is to base
NETTER'S CONCISE ORTHOPAEDIC ANATOMY 2O3
Hond . PHYSIcAL EXAM
Sensory testing
Ulnar nerve CB-T1 Radial nerve CS-CB
Sensorydistribution Sensorydistribution
Motor testing
Finger abduction.Interosseous m.Ulnar n. T1
4 f,ffi c//4,a/*4'l'/ ;onxo,cRA\-.,ro
Two-pointdiscrimination
Thumb extension.EPL. Radial nerve(PrN). C7
Finger extension.EDC. Radial nerve(PrN). C7
Anterior interosseous nerve dysfunction (paresis of flexordigitorum profundus and flexor pollicis longus muscles).
Median nerve C5-Tl
Sensory distribution
204 NETTER'S CONCISE ORTHOPAEDIC ANATOMY
PHYstcAt EXAM . Hond
When pinching a pieceof paper between thumband index finger, thethumb lP joint will flexif the adductor pollicismuscle is weak (ulnarnerve paralysis).
Thumb instability test
x{Y\fiv,iltrJBITNA.cRA\..ao
Elson test
Normal intact central slip
Stress test for ruptur-ed ulnar collateralligament of thumb(gamekeeper thumb) Abnormal ruptured central slip
Profundus test Stabilize PIPJ in extension, flex DIPJ only lnability to flex DIP alone indicates FDP pathology
Sublimus test Extend all fingers, flex a single finger at PIPJ lnability to flex PIP of isolated finger indicates FDS
pathology
Froment's sign Hold paper with thumb and index finger, pull
paperlf thumb lP flexion is positive, suggest adductor
pollicis weakness and/or ulnar nerve palsy
CMC grind test Axial compress and rotate CMC j0int Pain indicates arthritis at CIVC joint of thumb
Finger instabil- Stabilize proximal joint, apply varus and valgus Laxity indicates collateral ligament injury
ity test stress
Thumb Stabilize MCB apply valgus stress in extension
instability test and 30'of flexion
Laxity at 30": ulnar collateral ligament injury
Laxity in extension: accessory collateral ligament
and/or volar plate injury
Bunnell-Littler Extend MCPJ, passively flex PIPJ Tight or inability t0 flex PIPJ, improved with MCPJ
test flexion indicates tight intrinsic muscles
Elson test Flex PIPJ 90'over table edge, resist P2 exten- DIPJ rigidly extending (via lateral bands) indicatession central slip injury (boutonnidre)
NEITER S CONCISE ORTHOPAEDIC ANATOMY 205
Hond . oRtctNs AND tNsERnoNs
Abductor pollicis
Abductor pollicis
Opponens pollic
Flexor carpi r
Abductorbrevis
Flexor pollbrevis
Flexor pollicislongus
Adductor
ObliqueIransverse head
Flexor digitorum superf icial is
Flexor digitorum profundus
Palmar view
lexor pollicis brevis
Flexor carpi ulnaris
digiti minimi
Flexor digiti minimi brevis
carpi ulnaris
digiti minimi
Volar interossei
Abductor digiti minimi
lexor digiti minimi brevis
Muscle attachmentslI OriginsI lnsertions
Extensor carpiradialis brevis
Extensor carpiradialis brevis
Extensor carpiulnaris
Abductor pollicislongus
1ff,ffi4,t'/
Extensor digitorumcommunis (central slip)
Extensor digitorumcommunis (terminaltendons)
Dorsal vieri,
TrapeziumAbductor pollicis brevis
Flexor pollicis brevis
0pponens pollicis
CapitateAdductor pollicis
HamateFlex. digiti minimi brevis
0pponens digiti minimiPisilormAbductor digiti minimi
Dorsal interosseous
Palmar interosseous
Adductor pollicis
Abd. pollicis longus
0pponens pollicis
0pp. digiti minimiFlexor carpi radialis
Flexor carpi ulnarisExt. carpi rad. longus
Ext. carpi rad. brevisExtensor carpi ulnaris
Proximal phalanx
Ext. pollicis brevis (thumb)
Dorsal interossei
Abductor digiti minimi
Middle phalanx
Extensor digitorum com-munis (central slip)
Distal phalanx
Ext. pollicis longus(thumb)
Extensor digitorum com-munis (terminal tendon)
Proximal phalanx
Abductor pollicis brevis (thumb)
Flexor pollicis brevis (thumb)
Adductor pollicis (thumb)
Palmar interossei
Flexor digiti minimi brevisAbductor digiii minimi
Middle phalanx
Flexor digitorum superficialisDistal phalanx
Flexor pollicis longus (thumb)
Flexor digitorum profundus
206 NEI TER S CONCISE ORTHOPAEDIC ANATOMY
Anterior (palmar) view
Radial artery and palmar carpal branc
Ra
Superfieial palmar branch o[ radial artery
MUSCTES . Hond
Pronator quadratus muscle
Ulnar nerve
Ulnar artery and palmar carpal branch
Flexor carpi ulnaris tendon
lmar carpal arterial arch
form
digiti minimi muscle lcut)Deep palmar branch of ulnar arteryand deep branch of ulnar nerve
digiti minimi brevis muscle (cut)
Opponens digiti minimi muscle
Deep palmar (arterial) arch
metacarpal arteries
palmar digital arteries
transverse metacarpal ligaments
Transverse carpal ligamenl
Branches of median nerve
(f leror retinacu lu m ) lref I ected)
Opponens pollicis muscle
to thenar muscles and to 1 st
and 2nd lumbrical muscles
Abductor pollicisbrevis muscle lcut)
Flexorbrevis muscle
Adductormuscle
1 st dorsalinterosseous muscle
Branches from deepbranch of ulnar nerveto 3rd and 4th lumbricalmuscles and to allinterosseous muscles Lumbrical riuscles trel/ected)
NETTER,S CONCISE ORTHOPAEDIC ANATOIVIY 207
Hond . MUscLEs
1 st and 2nd lumbrical(un ipennate)
Posterior(dorsal) view
Abductor digitim tnlmt
Lumbrical muscles
lnterosseous muscles
Palmar interosseousRadius muscles (unipennate)
Radial arterv Deep trdnsverse' metacarpal
Abductor pollicis ligamentsbrevis muscle
Dorsalinterosseous
3rd and 4th lumbrical muscles(bipennate)
Flexor digitorumsuperficialis tendons (cut)
extensor expansions(hoods)
-il;':l::,", c/fddal*
4{ffirT\/
Lumbricals 1 &2 FDPtendons(radial 2)
Lumbricals3&4 FDPtendons(medial 3)
l\4edian Extend PlP, flex Only muscles in bodyl\4CP to insert on their own
Ulnar Extend plp flex antagonist (FDP) Pal--i;H -' mar to deep lrans-verse lVlC ligaments.
Radial lateral
bands
Radial lateral
bands
Proximal phalanx
and extensor
expansion (lat-
eral bands)
Digit abduction DAB: Dorsal ABductMCP flexion Bipennate: each belly
has separate insertion
lnterosseous: Adjacent Fxtensor expan- Ulnar Digit adduction pAD: palmar ADductpalmar (PlO) metacarpals sion (lateral Unipennate
bands)
208 NETTER,S CONCISE ORTHOPAEDIC ANATOMY
Thenar compartment
Carpal tunnelrelease
4ftr
l)orsal inc:ision 2
Dorsal interosseouscompartments
Transversecarpal Iigament
NETTER'S CONCISE ORTHOPAEDIC ANATOMY 209
Hond . NERVES
Cutaneous innervation of the hand
Anterior (palmar) viewMedial cutaneousnerye of forearm Flexor pollicis brevis muscle
(deep head only; superficialhead and other thenar mus-
Palmar'branch
Palmar/digitalbranches
M"diun I""*" I
Adductor
4 {ffi ffJ5:4.\'/
Common palmar digital nerve
CommunicatinB branch ofmedian nerve with ulnar nerve
Proper palmar digital nerves(dorsal digital nerves arefrom dorsal branch)
I branches to dorsum ofmiddle and distal phalanges
i}ltfiiili.{llli.,,.l ii:::'-1aLi1*::,?i.r::it:1._r,.,its':!:,ii..:t1€il
:,t:::.i:::i;:iai::::;:,::'+1:::.-=!?";:i:::t!:a#
Ulnar (C[7]B-Tl): Runs in forearm under FCU,0n FDP Domal cutaneous branch divides Scm proximal to wrist. Thisnerve continues into the dorsal aspect of the ulnar digits as dorsal digital nerves. Ulnar nerve enters Guyon's canal,then divides into superficial (sensory) and deep (motor) branches. The deep branch bends around the hook of the ha-mate and runs with the deep arterial arch, The superficial branch continues into the palmar aspect of the fingers as thepalmar digital nerves.
Sensory: Dorsal ulnar handt via dorsal cutaneous branchDorsal small & ring fingers: via dorsal digital branchesUlnar proximal palm: via palmar cutaneous branchUlnar distal palm: via common palmar digital branchesPalmar small & ring fingers: via proper palmar digital branches
Motor: Superficial(sensory)branch
" Palmaris brevis-only muscle innervated by this branchDeep (motor) branch: travels with deep arterial arch. Hypothenar compartment
. Abductor digiti minimi (ADM)
. Flexor digiti minimi brevis (FDMB)
. Opponens digiti minimi (0Dl\4). Adductor compartment
" Adductor pollicis. lntrinsic muscles
" Lumbricals (ulnar two B,4l). Dorsal interossei (Dl0)
" Palmar (volar) interossei (Vl0)o Thenar compartment. Flexor pollicis brevis (FPB|--deep head only
2IO NETTER S CONCISE ORTHOPAEDIC ANATOMY
Posterior (dorsal) viewMedial cutaneous:nerve of forearm
Division between ulnar \and radial n.ru. inn"rua- |
tion on dorsum of hand is Ivariable; it often aligns withfmiddle or 3rd digit instead I
of 4th digit as shown ,,1
l- Dorsal cutaneous'lI branch and clorsal
Ulnar ] digital branches -.nerve I properpalmar/I digital branches
r Musculo-Lateral cutaneous I
. " > cutaneousnerve ot torearm I/ nerve
Posterior cutaneous Inerve of forearm I o"n,r,y Superficial branch i n".u"fu and dorsal digital I
$ branches l
Proper palmar I Mediandigital branches / nerve
NERVES T HONd
Wrist and Hand: SuperficialRadial Dissection
Lateral (radial) view
Superficial branchradial nerve
Medial branch
Lateral branch
digita I
branches ofradial nerve
n::n,
{
Abductor pollicis l:
Opponens pollic
Superficial head.of flexor pollicis \
brevis (deep
head suppliedby ulnar nerve) Ji
almarcutaneousbranch
tingbranch of mediannerve withulnar nerve
Commonpalmardigitalnerves
carpalbranchof radiala rtery
1 st and 2ndlumbricalmuscles
Dorsal branches todorsum of middleand distal phalanges
4{wProperpalmardigitalneryes
BRACIIIAL.PLEXU$
Medial and Lateral Cords
Median (C[5]B-T1)i Runs in forearm on FDP Palmar cutaneous branch branches proximal to the carpal tunnel. The
median nerve enters the carpal tunnel, The motor recurrent branch exits distal to transverse carpal ligament (ICL)
and supplies the thenar muscles. Anatomic variants include exit through (at risk in carpal tunnel release) or under the
TCL. The remainder of the nerve is sensory and supplies the palmar radial 3% digits.
Sensory: Palm of hand: via palmar cutaneous branchVolar thumb, lF, MF, radial RF: via palmar digital branchesDorsal distal thumb, lE NilF, radial RF: via proper palmar digital branch
Motor: Motor (recurrent) branch. Thenar compartment. Abductor pollicis brevis (APB)
" Opponens pollicis. Flexor pollicis brevis (FPB)-superficial head only
. lntrinsic muscles. Lumbricals (adial two [1,2])
Posterior Cord
Radial (C5-Tl): Superficial branch runs under brachioradialis to wrist, then bifurcates in medial & lateral branches thatsupply the dorsal hand & thumb web space, They continue as dorsal digital branches to the dorsal fingers.
Sensory. Dorsal radial handr via superficial branchDorsal proximal thumb, lF, MF, radial RFr via dorsal digital branches
Motor: None (in hand)
NETTER,S CONCISE ORTHOPAEDIC ANATOMY 2II
Hond . ARTERIES
Superficial palmarbranch of radial arterv
Recurrent (motor)branch of mediannerve to thenarmuscles
Adductor pollicismuscle
Proper digitalnerves andarteries tothumb
Branches of medi
UInar artery and nerve
carpal ligament(flexor retinaculum)
Deep palmar branch of ulnar arteryand deep branch of ulnar nerve
ial branch of ulnar nerve
ommon ilexor sheath(ulnar bursa)
Superficial palmar (arterial) arch
palmar digital nervesand arteries
Communicating branch ofmedian nerve with ulnar nerve
Proper palmar digital nervesand arteries
nerve to 1 st and 2ndIumbrical muscles Branches of proper palmar digital
nerves and arteries to dorsum ofmiddle and distal phalanges
4{ff lnar artery and nerve
Palmar carpal branches ofradial and ulnar arteries
'Deep palmar branch ofulnar artery and deepbranch of ulnar nerve
to
Radial artery
Superficial palmar branch of radial
Deep palmar (arterial)
Princeps pollicis
Proper digital arteries andnerves of
Distal limit of superficialpalmar arch (Kaplan's line)
Radialis indicis
Palmar metacarpalCommon palmar digital
Proper palmar digitalProper palmar digital nerves frommedian nerve
hypothenar muscles
hranchof ulnar nerve
Deep palmar branch ofulnar nerve to 3rd and4th lumbrical, all interosseous, adductor pollicis,and deep head of flexorpollicis brevis muscles
'Proper palmar digitalnerves from ulnar nerve
2T2 NETTER'S CONCISE ORTHOPAEDIC ANATOMY
Section through distal interphal-angeal joint shows irregular, hyperplastic bony nodules (Heberden'snodes) at articular margins of distalphalanx. Cartilage eroded and jointspace narrowed
Radiograph of distal interphalangeal
ioint reveals Iate-stage degenerativechanges. Cartilage destruction andmargi nal osteophytes (Heberden'snodes)
DISORDERS o Hond
Radiograph shows cartilage thinning at proximalinterphalangeal joints, erosion of carpus andwrist ioint, osteoporosis, and finger deformities
Osteoarthritis
Late-stage degenerative changes incarpometacarpal articulation of thumb
Boutonniere deformity of index finger withswan-neck deformity of other fingers
Rheumatoid arthritis
. Loss of articular cartilage
. Due to wear or posttraumatic
. DIPJ #1 (Heberden's nodes)
. PIPJ #2 (Bouchard's nodes)
Hx: Elderly or hx ol injury
Pain: worse w/activityPE: Nodule/deformity, tender-
ness, decreased R0lvl
XR: 0A findings:joint space loss,
osteophytes, scle-
rosis, subchondral
cysts
1. NSAIDS
2. Steroid injection
3. Arthrodesis/fusion
4. Afthroplasty
. Ganglion cyst from arthriticjoint (DIPJ #1)
Hx: l\4ass near a joint
PE: Mass, +/- tenderness
XR: Joint arthritis L Excision of cyst and
associated osteoph!'te
. Autoimmune disease attacks
synovium and destroys joints. MCPJ #1. Multiple deformities develop
HX: Pain and stiffness (worse
in AM)
PE: Deformities (ulnar drift,
swan neck, boutonniere)
XR: Joint destruc-
tion
LABS: RE ANA, ESR,
CBC, uric acid
1. Medical management
2, Synovectomy (1 joint)
3, Tendon transfer/repair4. Arthrodesis/arthroplasty
. FDS insertion/volar plate injury
. Traumatic or assoc. with RA
. Lateral bands subluxate dorsally, hyperextends PIPJ
Hx lnjury or RA
PE: Deformity: flexed DIPJ,
injury hyperextended PIPJ
XR: Shows bony
deformity
1. Early: splint
2. Late: surgical release
and reconstruction
3, Arthrodesis
. Central slip (EDC) and triangu-lar ligament injury
. Traumatic or assoc. with RA
. Lateral bands subluxate volarly,
hyperflexes PIPJ
Hr Traumatic injury or RA
PE: Deformity: flexed PIPJ, +Elson's test (inability to ex-
tend the flexed PIPJ)
XR: Shows bony
deformity
1. Early: splint PIPJ in
extension
2. Reconstruct lateral
bands and central slip
3. Arthrodesis/arthroplasty
NETTER,S CONCISE ORTHOPAEDIC ANATOMY 2I5
Hond . DISoRDERS
Tenosynovitis Paronychia infection
fs
tuFreAreWWEponychium elevatedfrom nail surface
Horseshoe abscess#ffiffiWW€.4WWW
4{tr
Tenosynovitis of the middle finger. Treated with zigzagvolarincision. Tendon sheath opened by reflecting cruciate pulleysFine plastic catheter inserted for irrigation. Lines of incisionindicated for tendon sheaths of other fingers (A); radial andulnar bursae (B); and Parona's subtendinous space (C)
Felon
Begins as small nodule andspreads to hand, wrist, fore-arm (even systemically).
From focus in thumb spreadsthrough radial and ulnar bursaeand tendon sheath of little finger,with rupture into Parona's sub-tendinous space
Sporotrichosis
. Tendon sheath infection
. Usu, from puncture/bite
. May spread proximally
lnto deep spaces or
Parona's space (horse-
shoe abscess)
Hx: Pain and swelling
PE: Kanaval signs (4):
1, Flexed position
2, Fusiform swelling
3. Pain w/passive extension
4. Flexor sheath tenderness
XR: Plain films. r/oforeign body, air
LABS: CBC, ESR, CRP
1. Diagnosis <24hr: lV anti-biotics, close observation(l&D if no improvement)
2, Diagnosis >24hr: trriga-lion and debridement ofsheath + lV antibiotics
. Deep infection/abscess
in pulp of finger. Staph. aureus#l
Hx: Pain & swelling
PE: Pointing abscess, edema,erythema, +/ drainage
l. lncise and drain (must re-lease septum in pulp)
2. Antibiotics (lV vs oral)
. lnfection of nail fold
. #l hand infection
. Etiology: nail biting, hangnails
Hr Pain & swellingPE: E$hema, tenderness,+/- drainage
XR: Usually not needed 1. Early: warm soaks2. l&D and oral antibiotics
3. Partial nail excision
. Infection in deep spacesor tissues (e.9., thenar,hypothenar, Parona's
[horseshoe])
Hx: Pain & swellingPE: Edema, erythema, tender-
ness, fluctuance, +/- drain-age
XR: Usually normal
MR/CT May help ifdiagnosis is unclear
1. lncise & drain, lV abx2. Wound care/dressing
changes as needed
. Fungal (Sporothrix s.)in-fection from plants/roses
. Spreads via lymphatics
Hx Rash/discoloration
PE: Early: single noduleLate: multiple nodules/rash
Potassium iodine solution
2I4 NETTERS CONCISE ORTHOPAEDIC ANATOMY
Deep space infections
DISORDERS o Hond
lnfection ofmidpalmar spacesecondary totenosynovitisof middle iinger.Focus is infectedpuncture woundat distal crease.Line of incisionindicated
Infection of thenar space fromtenosynovitis o{ index fingerdue to puncture wound.
Dupuytren'sDisease *{ffi
4.t'/
Partial excisionof palmar fasciawith care to avoidneurovascular bundles
lnflammatory thickening of fibrous sheath (pulley) offlexor tendons with fusiform nodular enlargement o{both tendons. Broken line indicates line for incisionof lateral aspect of pulley
. Usually dominant hand
. "Fight bite": fist to mouth #l
. Bacteria: Strep., Staph. a.
Human: Eikenella corr.
Animal. P a ste u re l l a m u lt.
Hx: Bite, pain & swelling
PE: Puncture wound or
laceration, edema, +/-drainage, erythema (local
or tracking proximally)
XR: Hand series: rule
out foreign body(e.9., tooth) or air
in tissues/joint[ABS: CBC, ESR, CRP
1 . Td & rabies prophylaxis
if indicated
2. l&D, wound care
3, lV antibiotics (ampicillin/
sulbactam)
lil;llWrffi Fill},'t,,'$,l'"" ""'. Tighvthickened 41 pulley en-
traps flexor tendonr Associated with DM, RA, age. Congenital form in pediatrics
Hx: 40+, pain, snapping
or locking (esp. in AM)
PE: Tender flexor sheath,
snapping with flex./ext.
XR: Usually normal
MR: Not needed, PE
is diagnostic
1. Splint, occupational rx
2. Corticosteroid injection
into tendon sheath
3. A1 pulley release
Contracture of palmar fascia
lVyof ibroblasts create thickcords of type lll collagen
Associated with northern Euro-peans (AD), DM, EtoH
Hx: Usually male, 40+,c/o hand mass
PE: Nodule in palm, +/-coniracture of MCPJ or
PIPJ
XR: Usually normal
MR: Not needed if di-
agnosis is clear. May
be useful if etiology
of mass is unclear.
1, Early (mass, no contrac-ture): reassurance
2. Late (contracture): surgi-cal excision of cords
1ii,ii:ii111i11ili,.:,!:i:i,: ,,,,,,,,,.,,,,
. Ganglion-type cyst of the
flexor tendon sheath. Most common hand mass
Hx Small volar mass
PE: Firm, "pea"-size nod-
ule, does not moveWtendon
XR: Usually normal
MR: Not needed
1 . Aspiration/puncture
2. Surgical excision ifrecurrent
lt\
NETTERS CONCISE ORTHOPAEDIC ANATOMY 2T5
; tr"d . prorRrRrc DrsoRDERs
Incision lines(prefered method)
Dorsal aspect Palmar aspect
r5t
$lt-&ti{tlIatl
I,r
*irJ
iilI
,'
i'v
!
I
:;
t;rIt:!,t
. Failure of differentiation of finger tissue
. Most common congenital hand
anomaly. Complete (to finger tip) vs incomplete. Simple (soft tissue) vs complex (bone)
Hx: Finqers are connectedPE: Fingers are connected eitherto tip or incompletely down the
fingerXR: Will determine if bones are
fused (complex)
1. Should wait approximately 1yr. tllensurgically separate fingers
2. Careful incision planning and sknqrafts improve results
. Congenital finger flexion anomaly
. Usually PIPJ of small finger
. Type 'l (infants), type 2 (adolescents)
. Etiology: abnormal lumbrical or FDS
insertion
Hx: Finger flexed. Noticed at birth
or during adolescent growth
PE: lnability to fully extend joint
XR: Shows flexion, bones tvpi-cally normal
1 . Nonoperative: stretching, splint2. Functionally debilitating contrac-
ture : surgical relemltendontransfer
. Deviation of finger in coronal plane
. Radial deviation of small finger #1
. Etio: delta-shaped middle phalanx
Hx/PE: Deviation of finger, cos-metic and functional complaints
XR: Shows delta-shaped middlephalanx
l. Mild: no freatrnent2. Functional deficit surgical
conectior/realignment osteotomy
2T6 NETTER,S CONCISE ORTHOPAEDIC ANATOMY
PEDtATRtc DtsoRDERs . Hond
Congenital constriction band syndrome
a{w
. An extra thumb or portion thereol
. Wassel classification (7 types):Type 4 is most common
. Autosomal dominant or sporadic
. Associated with some syndromes
Hx/PE: Extra thumb or portion of thumbXR: Will show bifid or extra phalanges de-
pending on which type of duplication
1. Surgical reconstruction toobtain stable thumb. Gener-ally, retain ulnar thumb/structures & reconstruct
radial side (e.9,, type 4)
. Partial or complete absence ofthumb
. Blauth classrfication: Types l- V
. Treatment based on presence ofCMC joint
. Associated with some syndromes
Hx/PE: Small to completely absent thumbXR: Range of small, shortened, or absent
bones (phalanges, metacarpal, trapezium)Evaluate for presence of the CMC joint
1. Type l: Small thumb: no
treatment2. Types ll-lllA: Reconstruction3. Types lllB-V (no CMCJ): am-
putation & pollicization
. Constrictive bands lead to digitnecrosis or diminished growth/development,
. Nonhereditary
Hx/PE: ShoMruncated fingers with bands atlevel of diminished growth
XR: Small, shortened, or absent phalanges
1. Complete amputations ifneeded
2, Release/excise bands,Z-plasty as needed for skincoverage
NETTER'S CONCISE ORTHOPAEDIC ANATOMY 2I7
Hond o SURGICAL APPRoACHES
Volar approach to finger
Midlateral approach to finger
Flexorsheath
Jointligaments
F
J&HNA,€RA\**odigitorumsuperficialis
Flexordigitorumprofundus
lexortendons
. Flexor tendons (repair/explore)
. Digital nerves
. Soft tissue releases
. lnfection drainage
. Digital artery
. Digital nerve
. Flexor tendon
. l\4ake a "zigzag" incision connectingfinger creases
. Neurovascular bundle is lateral to thetendon sheath.
. Soft tissues are thin; capsule can beincised if care is not taken.
2I8 NETTER'S CONCISE ORTHOPAEDIC ANATOMY