1、Hand anatomy and examinationDr.Mihaela Hriscuplastic surgeonHand examination Look before you leap General observations:social/cultural background social/work requirementsHand examination-inspection Forearm Scars Hand posture Muscle wasting Deformities Shape of fingers Nails Colour,temperature,skin t
2、exture Sweating patternsHand examination Screening examination only now you can touchHand examination-sensation Compare light touch bilaterally Get the patient to pick up small objects Sensory mappingHand examination Taylor your examination according to the history and screening examinationHand exam
3、ination LOOK MOVE FEEL PROVOKEHand examination Finger chain Metacarpals Carpal chain Wrist ForearmHand examination Imagine the layers:*bone and joints *ligaments *tendons *neurovascular bundles *integument A)distal pulp B)proximal pulpFunctional units of the pulpDistal pulp(transversal cut)1.Nail pl
4、ate2.Nail bed3.Fat tissue4.Fibrous septa5.SkinArrangement of dermatoglyphs A)distal pulp B)proximal pulpTip pinchProximal pulp(transversal section)Fibrous septa Fat tissueVascularisation of the pulp1.Pulp arcade2.Palmar collateral artery3.Flexor tendon4.Terminal branch of the pulp5.Central artery of
5、 the pulp6.Collateral branch of the pulp archFunctional anatomy af the mid-palmar digital areaA)Topographical limits of the palmar digital surfaceB)Transversal section through the middle phalanx 1.Clelands ligamentC)Cutaneous functional units,volar aspect of the digit 1.Pulp 2.and 3.Mid-palmar digit
6、al areaVascular anatomy,palmar aspect of the digitDeep venous network,venae comitantesA)Type 1:complete deep venous network 1.Distal anastomotic venous arch 2.Proximal anastomotic venous archB)Type 2:proximal deep venous network-draind directly into the dorsal network(4)through the intermediary comm
7、unicating oblique branch(3)C)Type 3:the deep venous network segment is present only between the two anastomotic arches(1)and(2)Dorsal skin of the digitsA)In full extension a relative excess of the skin exists at the PIP and DIP levelB)Transversal sectionC)This excess of skin is“absorbed”in full flex
8、ionLimits od the dorsal cutaneous functional units of the digitsBlood supply of the dorsal aspect of the thumb1.Dorso-radial thenar branch2.Dorso-ulnar branch from 1-st dorsal metacarpal artery3.1-st dorsal metacarpal artery4.Radial arteryBlood supply of the dorsal aspect of the digits:1-st and 2-nd
9、 intermetacarpal spaces1.1-st intermetacarpal dorsal artery2.2-nd intermetacarpal dorsal arteryBlood supply of the dorsal aspect of the digits:3-rd and 4-th intermetacarpal spaces1.Dorsal metacarpal network2.Anastomotic palmar arch3.Palmar collateral arteryParticipation of the palmar collateral arte
10、ries to the blood supply of the dorsal aspect of the digitAnatomy of the nail and the perionychium1.Hyponychium2.Nail plate3.Nail bed4.Lunula5.Eponychium6.Nail bed7.Nail matrixVascularisation of the nail1.Distal arch2.Proximal arch3.Pulp arch4.Superficial arch5.Volar collateral arteryHand muscles an
11、d tendons-volar superficial Anatomy of synovial sheaths of the flexor tendons1.The index,middle and ring fingers have individual sheaths in the digit2.The FPL has its own sheath3.The little finger has a common sheath with the flexor tendons aof the long digits The pulleys of the long digitsThe fibro
12、-osseous tunnel is formed by:5 annular pulleys(A1 to A5)and 3 cruciform pulleys(C1 to C3)The pulleys of the flexor pollicis longus Two annular pulleys A1 and A2 and an oblique pulley A3 constitute the fibro-osseous sheathThe organisation of the vascular system of the flexor tendons FDP(1)and FDS(2)i
13、n the fibro-osseous tunnel;each tendon is vascularised by a vinculum brevis(3)and vinculum longus(4)Clinical examination A.test of the FDPB.test of the FDSC.test of the FPLAnatomy of extrinsec extensor tendons1.Juncturae tendinum2.EPDQ3.EDC4.ECU5.EPL6.EPB7.Synovial sheath8.Retinaculum9.ECRL10.ECRBAn
14、atomy of extensor apparatus of the digit1.Interosseous muscle2.EDC3.Sagittal band4.Extensor hood5.Central slip(base of the middle phalanx)6.Lateral bands7.Triangular lig.8.Insertion of extensor tendon at the base of distal phalanx9.Intermetacarpal volar lig.10.Lumbrical11.Transverse retinacular lig.
15、12.Oblique retinacular lig.Test of the EPLThe hand is placed flat and pressure is applied to the nail,the patient is asked to raise his thumb.Only the EPL wich projects onto the internal side of the snuff-box can produce this movementTest of EPB The MP joint being flexed,the patient is asked to stre
16、tch this joint against the pressure applied to the first phalanxTest of extensor proprius index and little finger The patient makes“horns”Test of EDC Is effectuated against pressure applied to each phalanx The integrity of the insertion of the tendon at the base of the distal phalanxVesselsSensitive inervation of the hand1.Ulnar nerve2.Median nerve3.Radial nerveNervesMedian and ulnar nerve block at the wristRadial nerve block at the wristDigital nerve block The needle is introduced in the intermetacarpal space at an angle around 15 maximum.The penetration of the needle is between 20-25 mm
