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Dissector Answers - Extensor Compartment of the Forearm, Deep Hand, Wrist and Hand

Joints

Learning Objectives:
Upon completion of this session, the student will be able to:
1. Identify the extensor compartment; nerves and vessels supplying their contents; functional significance.
2. Describe the position of tendons, associated bursae, nerves, and vessels beneath the palmar carpal ligament.
3. Identify the prominent features of carpals, metacarpals and phalanges associated with the hand as listed in the lab manual.
4. Define the thenar, hypothenar, central, and adductor-interosseous compartments of the hand and the functional significance of each.
5. Correlate any fractures or deep cuts of the hand with functional disruptions of associated muscular and neurovascular structures.
6. Describe the movements of the fingers and thumb.
7. Describe the collateral circulation of the hand.

Learning Objectives and Explanations:


1. Describe the position of tendons, associated bursae, nerves, and vessels beneath the palmar carpal ligament.
This needs about 1,000 words. ( N461, N462, TG2-24, TG2-34A, TG2-34B)

left upper quadrant

left lower quadrant

1. Palmar carpal ligament

5. Radial a.

2. Tendon of flexor carpi


radialis m.

6. Tendon of extensor carpi


radialislongus m.

3. Tendon of extensor
pollicisbrevis m.
4. Tendon of abductor
pollicislongus m.

right lower quadrant


12. Tendon of extensor
digitorumcommunis m.

right upper quadrant


19. Abductor digitiminimi m.
20. Tendon of flexor carpi ulnaris m.

13. Extensor retinaculum

7. Articular cavities

14. Hamate

8. Tendon of extensor carpi


radialisbrevis m.

15. Tendon of extensor


digitiminimi m.

21. Tendons of flexor digitorumprofundus


m.
22. Ulnar a. and n.
23. Palmaris brevis m.

9. Scaphoid

16. Triquetral
24. Flexor retinaculum

10. Tendon of extensor


indicis m.

17. Tendon of extensor carpi


ulnaris m.

11. Capitate

18. Radiate carpal ligament

25. Tendons of flexor pollicislongus and


flexor digitorumsuperficialis mm.
26. Median n.
27. Tendon of palmarislongus m.

2. Identify the prominent features of carpals, metacarpals and phalanges associated with the hand as listed in the lab manual. ( N452, N456, TG2-31,
TG2-32)

carpals: These eight small bones of the wrist are held together by ligaments and arranged in two (irregular) rows, proximal and distal.
The bones of the proximal row, listed from the radial to the ulnar side, are the scaphoid, the lunate, the triquetrum, and the pisiform.
In the distal row, from radial to ulnar side, are the trapezium, the trapezoid, the capitate, and the hamate. Read across the proximal
layer of bones: Send Louis ToParis. Read across the distal layer of bones: To Tame Carnal Hunger, or the more racey: Some Lovers
Try Positions That They Can't Handle. Can you guess which is the favorite of medical students? (Note that the pisiform bone is a
sesamoid bone in the tendon of the flexor carpi ulnaris, so it sits on the volar surface of the triquetrum.)

metacarpals: There are five metacarpal bones, numbered from 1 (the thumb) to 5 (the little finger). These bones are just distal to the
carpals.

phalanges: There are fourteen of these "bones of the fingers." The thumb has only two phalanges, a proximal and distal, whereas the
other digits each have three phalanges, proximal, middle, and distal.

Extensor Muscles

a. superficial extensors:
Muscle

Origin

Insertion

Action

Innervation

Blood
Supply

brachioradialis

upper two-thirds of the lateral


supracondylar ridge of the
humerus

lateral side of the base of the flexes the elbow, assists in radial nerve
styloid process of the radius pronation & supination

radial
recurrent a.

extensor carpi
radialislongus

lower one-third of the lateral


supracondylar ridge of the
humerus

dorsum of the second


metacarpal bone (base)

extends the wrist; abducts radial nerve


the hand

radial a.

extensor carpi
radialisbrevis

common extensor tendon (lateral


epicondyle of humerus)

dorsum of the third


metacarpal bone (base)

extends the wrist; abducts deep radial


the hand
nerve

radial a.

extensor
digitorum

common extensor tendon extensor expansion of


(lateral epicondyle of the digits 2-5

extends the metacarpophalangeal,


proximal interphalangeal and distal

deep
radial

interosseous
recurrent a. and

extensor
digitiminimi

humerus)

interphalangeal joints of the 2nd-5th


digits; extends wrist

nerve

posterior
interosseous a.

common extensor tendon joins the extensor


(lateral epicondyle of the digitorum tendon to the
humerus)
5th digit and inserts into
the extensor expansion

extends the metacarpophalangeal,


proximal interphalangeal and distal
interphalangeal joints of the 5th digit

deep
radial
nerve

interosseous
recurrent a.

extends the wrist; adducts the hand

deep
radial
nerve

ulnar a.

extensor carpi common extensor tendon medial side of the base of


ulnaris
& the middle one-half of the 5th metacarpal
the posterior border of
the ulna
b. deep extensors:
Muscle

Origin

Insertion

Action

Innervation Blood Supply

supinator

lateral epicondyle of the humerus, lateral side of proximal


supinator crest & fossa of the
one-third of the radius
ulna, radial collateral ligament,
annular ligament

supinates the forearm

deep radial
nerve

recurrent
interosseous
a.

abductor
pollicislongus

middle one-third of the posterior radial side of the base of


surface of the radius, interosseous the first metacarpal
membrane, mid-portion of
posterolateral ulna

abducts the thumb at


carpometacarpal joint

deep radial
nerve

posterior
interosseous
a.

extensor
pollicisbrevis

interosseous membrane and the


posterior surface of the distal
radius

base of the proximal


phalanx of the thumb

extends the thumb at the


metacarpophalangeal joint

deep radial
nerve

posterior
interosseous a

extensor
pollicislongus

interosseous membrane and


middle part of the posterolateral
surface of the ulna

base of the distal phalanx


of the thumb

extends the thumb at the


interphalangeal joint

deep radial
nerve

posterior
interosseous a

extensor
indicis

interosseous membrane and the


posterolateralsurface of the distal
ulna

its tendon joins the tendon


of the extensor digitorum
to the second digit; both
tendons insert into the

extends the index finger at the


metacarpophalangeal, proximal
interphalangealand distal
interphalangeal joints

deep radial
nerve

posterior
interosseous a

extensor expansion
extensor division:

muscles which extend the hand at the wrist:


o extensor carpi radialislongus (superficial group, posterior compartment)
o extensor carpi radialisbrevis (superficial group, posterior compartment)
o extensor carpi ulnaris (superficial group, posterior compartment)

muscles which extend the digits, except the thumb:


o extensor digitorum (superficial group, posterior compartment)
o extensor indicis (deep group, posterior compartment)
o extensor digitiminimi (superficial group, posterior compartment)

muscles which operate in extension or abduction of the thumb:


o abductor pollicislongus (deep group, posterior compartment - abducts thumb)
o extensor pollicisbrevis (deep group, posterior compartment)
o extensor pollicislongus (deep group, posterior compartment)

The wrist joint, also called the radiocarpal articulation, has great movement ability because of its convex oval articular surface. The
joint can flex, extend, abduct, adduct and circumduct. Rotary motion is prohibited.

The "knuckles", or metacarpophalangeal joints (MP), are characterized by loose articular capsules. Movements of flexion and
extension, abduction and adduction and circumduction are permitted at these joints. Extension is making a flat hand; flexion is making
a fist. The metacarpophalangeal joint of the thumb is limited to the actions of flexion and extension. (The thumb's freedom of
movement is a result of its carpometacarpal joint).

3. Define the thenar, hypothenar, central, and adductor-interosseous compartments of the hand and the functional significance of each. ( N447, N448,
N459, N460, N461, N465, N466, N468, N472A, N472B, N459, N460, N462, TG2-34A, TG2-34B, TG2-35A, TG2-35BC)
The hand is entirely wrapped in fascia, with the palmar and dorsal fascia being continuous with one another on both sides. This fascia is relatively
thin, except in a triangular area on the middle of the palm. Here the fascia, which is also connected to the flexor retinaculum and palmarislongus
tendon (if present) is called the palmar aponeurosis. Furthermore, just like in the lower limb and in the arm and forearm, there are septa that further
divide the space into compartments.
In the palm of the hand, there are three important septa. The lateral fibrous septum runs from the lateral part of the palmar aponeurosis to the deep
aspect of the third metacarpal. This septum is the border between the thenar compartment lateral to it (towards the thumb) and the central
compartment medial to it. Similarly, the medial fibrous septum runs from the medial aspect of the palmar aponeurosis to the deep part of the fifth
metacarpal. It separates the hypothenar compartment, which is medial, towards the little finger, from the aforementioned central compartment.
Finally, a septum runs medially from the medial side of the first metacarpal to the deep part of the third metacarpal. It separates the more superficial
thenar compartment from the deeper adductor compartment.
The intrinsic muscles of the hand are listed below, divided by compartment.
thenar compartment:
Muscle

Origin

Insertion

Action

Innervation

Blood Supply

abductor
pollicisbrevis

flexor retinaculum,
scaphoid, trapezium

base of the proximal


phalanx of the first
digit

abducts thumb

recurrent branch of superficial palmar


median nerve
br. of the radial a.

flexor
pollicisbrevis

flexor retinaculum,
trapezium

proximal phalanx of
the 1st digit

flexes the carpometacarpal and


metacarpophalangeal joints of the
thumb

recurrent branch of superficial palmar


the median nerve
br. of the radial a.

opponenspollicis

flexor retinaculum,
trapezium

shaft of 1st
metacarpal

opposes the thumb

recurrent branch of superficial palmar


median nerve
br. of the radial a.

adductor/interosseous compartment:
Muscle
adductor

Origin
oblique head: capitate

Insertion
base of the proximal

Action
adducts the thumb

Innervation
ulnar

Blood
Supply
deep palmar

pollicis

and base of the 2nd and


3rd metacarpals;
transverse head: shaft of
the 3rd metacarpal

phalanx of the thumb

nerve, deep arterial arch


branch

dorsal
four muscles, each
interosseous arising from two
(hand)
adjacent metacarpal
shafts

base of the proximal


phalanx and the
extensor expansion on
lateral side of the 2nd
digit, lateral & medial
sides of the 3rd digit,
and medial side of the
4th digit

flex the metacarpophalangeal


ulnar
dorsal and
joint, extend the proximal and
nerve, deep palmar
distal interphalangeal joints of
branch
metacarpal
digits 2-4, abduct digits 2-4
aa.
(abduction of digits in the hand is
defined as movement away from
the midline of the 3rd digit)

palmar
three muscles, arising
interosseous from the palmar surface
of the shafts of
metacarpals 2, 4, & 5 (a
palmar interosseous for
the thumb is usually
fused with the adductor
pollicis m.)

base of the proximal


phalanx and extensor
expansion of the
medial side of digit 2
and lateral side of
digits 4 & 5

flexes the metacarpophalangeal,


extends proximal and distal
interphalangeal joints and
adducts digits 2, 4, & 5
(adduction of the digits of the
hand is in reference to the
midline of the 3rd digit)

ulnar
palmar
nerve, deep metacarpal
branch
aa.

hypothenar compartment:
Muscle
abductor digitiminimi
(hand)

Origin
pisiform

Insertion

Action

Innervation

Blood
Supply

base of the proximal


phalanx of the 5th digit on
its ulnar side

abducts the 5th digit

ulnar nerve,
deep branch

ulnar a.

flexor digitiminimibrevis hook of hamate &


(hand)
the flexor
retinaculum

proximal phalanx of the


5th digit

flexes the carpometacarpal and


metacarpophalangeal joints of the 5th
digit

ulnar nerve,
deep branch

ulnar a.

opponensdigitiminimi

shaft of 5th metacarpal

opposes the 5th digit

ulnar nerve,
deep branch

ulnar a.

hook of hamate and


flexor retinaculum

central compartment:
Muscle
lumbrical
(hand)

Origin
flexor
digitorumprofundus
tendons of digits 2-5

Insertion

Action

Innervation

extensor expansion on flex the metacarpophalangeal joints,


the radial side of the
extend the proximal and distal
proximal phalanx of
interphalangeal joints of digits 2-5
digits 2-5

Blood Supply

median nerve (radial 2) via superficial


palmar digital nerves
palmar arterial
&ulnar nerve (ulnar 2) via arch
deep branch

And finally, we have poor little palmarisbrevismuscle. As if it isn't bad enough that the palmarislongus muscle is highly variable, its little brother,
the palmarisbrevis muscle, is thin, largely insignificant mechanically, and is superficial to, not in, the hypothenar compartment. It does serve to
protect the ulnar nerve and artery, which it does valiantly, as well as give you that funny little skin pucker when you make a tight fist.
Muscle

Origin

palmarisbrevis fascia overlying the


hypothenar eminence

Insertion
skin of the palm near the
ulnar border of the hand

Action
draws the skin of the ulnar side of the
hand toward the center of the palm

Innervation

Blood
Supply

superficial br. of the ulnar a.


ulnar n.

To summarize innervation, there are two main nerves. The median nerve gets the thenar muscles via its recurrent (motor) branch, as well as half
of the lumbricals. The deep branch of the ulnar nerve gets all of the rest, with the exception of the palmarisbrevis muscle, which is innervated by a
superficial branch of the ulnar nerve.
4. Correlate any fractures or deep cuts of the hand with functional disruptions of associated muscular and neurovascular structures.
The two classic examples here both involve the median nerve:
Injury to the median nerve at the wrist, in, say, a case of carpal tunnel syndrome, results in severe paralysis of some hand motions and loss of
cutaneous sensation. Most noticeable is the loss of the ability to oppose the thumb, since the only muscle that does this for the thumb is an intrinsic
hand muscle innervated by the median nerve, the opponenspollicis muscle. (Other intrinsic muscles of the hand can call for back-up from forearm
muscles, to, for example, flex the thumb or little finger. These actions will, of course, be weakened somewhat.) (Hint: Know about carpal tunnel
syndrome.)
Often, farm equipment, switchblades, or broken glass can produce a direct wound to the thenar eminence, possibly injuring the recurrent (motor)
branch of the median nerve itself. This also paralyzes the muscles of the thenar eminence, and causes subsequent wasting of the area. But,
depending on what branches had already been given off, the lesion may be less severe than one caused farther up the chain at the wrist.

Other injuries are of course possible. Use your imagination to figure out what things one could cut when falling with arms outstretched through a
plate-glass window, then use the tables to figure out how that person would present to you in the Emergency Department.
5. Describe the movements of the fingers and thumb. (N463, N464, N465, TG2-45, TG2-24)
The flexion and extension of the fingers is pretty straightforward. Abduction and adduction of them is the same as with the toes, with the third digit
(2nd finger, "middle" finger) held as the axial line. The other three fingers either move toward (adduction) or away from (abduction) this finger.
The thumb gets to be a little tricky. Opposition is where you bring the pad of the thumb into contact with the pad of another digit, often specifically
the little finger. This "simple" motion, which sets us apart from all but our closest monkey cousins, is really quite complex. But, the rest of the
"standard" motions of the thumb are defined differently than for the other digits. Abduction is bringing the thumb out, away from the plane of the
palm. Make a hand puppet, then straighten your MP joints. Your thumb is abducted. Clearly, bringing it back, then, is adduction. Extension of the
thumb takes place as you move it away from the other digits within the plane of the palm, like when hitchhiking or making the "L for loser" sign on
your forehead. Flexion is not only bringing it back, but then further moving it such that it is lying across the palm.
6. Describe the collateral circulation of the hand. (N466, N469, TG2-37A, TG2-37B)
There are a bunch of places in the hand where arterial anastomosis occurs:

both the superficial and deep palmar arches get blood from both the radial and ulnar arteries

palmar metacarpal arteries with the common palmar digital arteries

the perforating branches of the dorsal metacarpals with both the deep palmar arch and the common palmar digital arteries

the proper dorsal arteries with the palmar digital arteries

Questions and Answers:


7. Locate the palmar digital branches of the median and ulnar nerves along the borders of the digits. Determine area of distribution. Do they supply
any portion of the dorsal side of the digit? How much? Significance? What do they accompany?
The proper palmar digital branches of median nerve reach the radial 3 and 1/2 digits, while the ulnar branches reach the remaining ulnar 1 and 1/2
digits. Each palmar digital branch sends branches onto the dorsal surface of the distal phalanx, to supply the nail bed. Proper palmar digital arteries,
primarily from the superficial palmar arterial arch, travel with the nerves. (N468,N472A, TG2-33B, TG2-38A)
8. What is the relation of the palmar aponeurosis to palmarislongus tendon, the palmar carpal ligament, and the flexor retinaculum?

The palmarislongus tendon spreads to unite with the palmar aponeurosis. The tendon passes deep to the palmar carpal ligament, and superficial to the
flexor retinaculum. (N459, N460, N461, TG2-23, TG2-24)
9. Identify the superficial transverse metacarpal ligament and transverse fasciculi and note the gaps between them. What can be seen in these gaps?
The common palmar digital neurovascular bundles can be found dividing into their proper palmar digital branches in these gaps. (N459, TG2-33)
10. What is the carpal tunnel and its associated syndrome?
The anatomy tables cover it well. It says that carpal tunnel syndrome: "results from any lesion that significally reduces the size of the carpal tunnel.
Fluid retention, infection, and excessive exercise of the fingers may cause swelling of the tendons or their synovial sheaths. Median nerve is the most
sensitive structure in the carpal tunnel and therefore is the most affected. Median nerve has sensory branches to the lateral three and a half digits thus
paresthesia (abnormal sensation), hypothesia (reduced sensation), or anesthesia (loss of sensation) may occur. Furthermore, the main motor branch of
the median nerve is the recurrent branch which serves three thenar muscles (it also serves the radial 2 lumbricals via common palmar digitals).
Continued compresion of the median nerve will lead to weakness of the abductor pollicisbrevis and opponenspollicis. To relieve the symptoms,
partial or complete surgical division of the flexor retinaculum (carpal tunnel release) may be necessary. Clinically this syndrome can be tested for by
tapping on the carpal tunnel. If symptoms are elicited (positive Tinel's sign), the syndrome is likely." (N461,N472A,N475, TG2-34A, TG2-34B,
TG2-35)
11. What artery completes the superficial palmar arterial arch?
The superficial palmar branch of the radial artery completes the superficial palmar arterial arch. (N466, TG2-37)
11a.How do median and ulnar nerves share in the cutaneous innervation of the digits (review)?
Median nerve branches reach the radial 3 1/2 digits, while ulnar branches reach the remaining ulnar 1 1/2 digits. This includes the dorsal surface of
the distal phalanx, to supply the nail bed. (N472, TG2-33, TG2-38)
12. Does the flexor pollicisbrevis muscle have a deep head?
Yes, the deep head arises from the trapezoid and capitate, while the superficial head arises from the flexor retinaculum and the trapezium. (N465,
TG2-34)
13. Trace the superficial palmar branch of the radial artery to the thenar compartment. Does it continue beyond the compartment? Where?
The superficial palmar branch of radial artery completes the superficial palmar arch by passing into the central compartment, deep to the palmar
aponeurosis. (N466, TG2-37A, TG2-37B)
14. What is the source of innervation for the hypothenar muscles?
As discussed in #3 above, the deep branch of ulnar nerve innervates these muscles. It passes between the abductor digitiminimi and flexor
digitiminimibrevis muscles. (N465,N459, TG2-34A, TG2-34B)
15. Examine the contents of the carpal tunnel. How is it formed?
The carpal tunnel is formed by the attachment of the flexor retinaculum to the trapezium and scaphoid laterally, and the hook of the hamate and the
pisiform medially. (N461, TG2-34)
16. Into which digital sheath does the ulnar bursa continue distally?
The ulnar bursa continues into the sheath for the little finger flexor tendons, which means that an infection of the little finger involving its flexor and
synovial sheaths could lead to an infection within the carpal tunnel. (N464, TG2-34)
17. What are vincula?
Vincula (mesotendons) are folds of synovial membrane containing neurovascular pedicles supplying the flexor tendons. They are located between the
phalanges and the flexor tendons. (N464, TG2-45)
18. Identify the lumbrical muscles, noting origin. Trace them to their immediate and functional insertion. What is the course of innervation?

The radial 2 lumbricals are innervated by the median nerve, via its palmar digital branches. The ulnar 2 lumbricals are innervated by the ulnar nerve.
(N463, N464,N475,N459, TG2-34A, TG2-34B)
19. Locate the flexor carpi radialis tendon. Is it in the carpal tunnel? What happens to it?
The tendon of flexor carpi radialis traverses a split in the flexor retinaculum to insert on the bases of the second and third metacarpals. (N461, TG236)
20. Consider the complete blood supply to the hand, including sources and arches . How do the dorsal and palmar proper digital arteries differ in their
formation? What are perforating arteries? Where are they found? What is their function?
The superficial palmar arch is formed by the superficial branch of the ulnar artery and the superficial palmar branch of the radial artery. The deep
palmar arch is primarily formed by the radial artery anastomosing with the deep branch of the ulnar artery. Dorsal carpal branches of radial and ulnar
unite to form a dorsal carpal arch. This arch gives off dorsal metacarpal arteries which divide into the dorsal digital arteries. Palmar digital arteries are
branches of common digital branches of the superficial arch. Perforating arteries connect the dorsal and palmar metacarpal arteries (from the deep
arch) at the heads of the metacarpal bones. (N466, TG2-37A, TG2-37B)

Clinical Cases - Hand


A 28-year-old dentist consults her physician, complaining that she feels tingling and slight pain in her right hand. The symptoms are localized to her
thumb, index, middle and lateral side of her ring finger. The sensations are more intense at night or if she overworks. Recently, she has experienced

some weakness in her grasp and finds it more difficult to hold her instruments. Also, movements of her right thumb are not as strong as before.
On examination, there is loss of power on certain movements of the thumb. She has impaired appreciation of light touch and pin pricks to the thumb,
index, middle and lateral side of her ring finger, but sensation to her palm is not affected. Pressure and tapping over the flexor retinaculum causes
tingling. After a complete examination, the patient is diagnosed with carpal tunnel syndrome.
Questions to consider:
1. What is the carpal tunnel? What is contained in it?
The carpal tunnel is a canal at the wrist made up of the carpal bones and flexor retinaculum. The tunnel houses the tendon of the flexor
pollicislongus in its synovial sheath, the tendons of the flexor digitorumsuperficialisand profundus in their common synovial sheath
and the median nerve.
2. Two muscles that are affected by carpal tunnel syndrome are the abductor pollicisbrevis and the opponenspollicis. How would you test
their function?
The abductor pollicisbrevis pulls the thumb away from the palm at a right angle. One way to test this is to lie the forearm on a table,
palm up and ask the patient to point their thumb towards the ceiling. At the same time, you can push down on the thumb to give some
resistance.
The opponenspollicis pulls the thumb across the palm towards the base of the little finger. Ask the patient to do this against resistance.
3. Physicians used to think this kind of pain was caused by a deficiency in the brachial plexus. If this was the case, what roots or trunks
would have to be involved and why is this unlikely to be the cause of the problem? (Consider both sensory and motor deficiencies that
this patient has.)
If this patient's symptoms were caused by a deficiency in the brachial plexus, practically all roots from C6 to T1 would have to be
involved. The sensory dermatome of that region comes from the ventral rami of C6 and C7, which compose part of the upper and all
of the middle trunk of the brachial plexus. The motor supply to the muscles involved come from segments of C8 and T1. Such a
widespread lesion, however, would be unlikely to have such limited symptoms.

4. What causes the symptoms of carpal tunnel syndrome?


Carpal tunnel syndrome is caused by a compression of the median nerve. This can be due to the inflammation of the common flexor
tendon sheath after strain and overexertion. Fluid retention, as seen in pregnancy and hormonal imbalances, can also cause

compression of the nerve. Patients often feel an increase in symptoms at night due to venous stasis. Venous stasis contributes to the
compression of the nerve.
5. Although this patient recovered with rest and physical therapy, some patients do not improve with conservative treatment and opt for
surgery. What structures might be endangered by surgery and need to be avoided?
Surgery can decompress the median nerve. Structures superficial to the flexor retinaculum, however, can be endangered. This includes
the superficial palmar vascular arch formed by the superficial branch of the ulnar artery and superficial branch of the radial artery, the
palmar cutaneous branches of the median and ulnar nerves and the recurrent motor branch of the median nerve.

Practice Quiz - Hand

Below are written questions from previous quizzes and exams. Click here for a Practical Quiz - old format or Practical Quiz - new format.
1. The extensor expansion of the ring finger receives tendons from all of the following EXCEPT:
Dorsal interosseus
Extensor carpi ulnaris
Extensor digitorum
Lumbrical
Palmar interosseus
The correct answer is:

Extensor carpi ulnaris

The tendons from the extensor digitorum muscles flatten to form extensor expansions on the distal ends of the metacarpals and along the
phalanges. The dorsal and palmar interosseus muscles and the lumbricals are inserting into these extensor expansions. Extensor carpi ulnaris
inserts on the medial side of the base of the 5th metacarpal--it is not inserting near the extensor expansions.
2. A girl playing softball cuts the palm of her hand as she scoops up a piece of glass along with the ball. If the only nerve
damaged is the recurrent branch of the median nerve, she would lose what movement of the thumb?
Abduction
Adduction
Flexion of the distal phalanx
Opposition

The correct answer is:

opposition.

If the recurrent branch of the median nerve was injured, abductor pollicisbrevis, flexor pollicisbrevis, and opponenspollicis would be
denervated. Opponens is the only muscle that allows for opposition of the thumb. So, by denervatingopponens, the girl would no longer be
able to oppose her thumb. Although abductor pollicisbrevis would be denervated, abductor pollicislongus would still be functional, so she
could abduct her thumb. Adductor pollicis is in the adductor/interosseous compartment, deep in the center of the hand, and it is innervated by

the deep branch of the ulnar nerve. This means that adduction would not be affected by the injury to the recurrent branch of the median nerve.
Although flexor pollicisbrevis was denervated, this is not the flexor that is responsible for flexion at the distal phalanx. Flexor pollicislongus
controls flexion at the distal phalanx, and it is a muscle of the forearm which is innervated by the median nerve.

3. The main source of blood to the superficial palmar arterial arch is the:
Deep branch of the ulnar artery
Radial artery
Superficial palmar branch of the radial artery
Ulnar artery

The correct answer is:

ulnar artery

The ulnar artery is the main source of blood to the superficial palmar arterial arch; the arch is completed on the radial side by the superficial
palmar branch of the radial artery. The radial artery is the main source of blood to the deep palmar arterial arch, which is completed on the
ulnar side by the deep branch of the ulnar artery.
4. What sesamoid bone develops in the tendon of flexor carpi ulnaris and is therefore not a part of the wrist joint?
Capitate
Lunate
Pisiform
Scaphoid
Triquetral

The correct answer is:

pisiform

The pisiform is a sesamoid bone in the tendon of the flexor carpi ulnaris muscle. It is in the proximal row of carpal bones. It bears the forces
generated by the tendon as the tendon rides across triquetrum, especially during wrist extension. Capitate is the largest carpal bone. It is in the
distal row of carpal bones, and it transmits forces generated in the hand to lunate and then to the radius. Lunate is a carpal bone in the
proximal row which articulates with capitate. Scaphoid is the most lateral carpal bone in the proximal row. It is found in the floor of the
anatomical snuff box and it is the most frequently fractured carpal bone.
5. In order to check the pulse of a child whose forearm is in a cast, the pediatrician presses her finger into the depth of the
"anatomical snuffbox". The tendon lying immediately medial (ulnar) to the physician's finger belongs to what muscle?
Brachioradialis
Extensor carpi radialisbrevis
Extensor carpi radialislongus
Extensor pollicisbrevis
Extensor pollicislongus

The correct answer is:

extensor pollicislongus

The anatomical snuff box is bounded on the ulnar side by the tendon of extensor pollicislongus. It is bounded radially by the tendons of
abductor pollicislongus and extensor pollicisbrevis. The radial artery lies in the floor of the snuff box, and scaphoid can be felt in the floor of
the anatomical snuff box. Extensor carpi radialislongus and brevis attach their tendons to the base of the second and third metacarpals,
respectively. Brachioradialis inserts its tendon on the lateral side of the base of the styloid process of the radius.

6. While watching her boyfriend split wood, a teenager was struck on the back of her carpals by a sharp- edged flying wedge.
Her extensor digitorum tendons were exposed, though not severed, indicating that the surrounding synovial sheath had

been opened. What other muscle has its tendon surrounded by the same synovial sheath?
Extensor carpi radialisbrevis
Extensor carpi radialislongus
Extensor digitiminimi
Extensor indicis
Extensor pollicislongus

The correct answer is:

Extensor indicis

Extensor indicis is a deep forearm extensor that extends the index finger only. Its tendon joins the tendon of the extensor digitorum which
goes to the second digit, and both tendons insert into the extensor expansion. Since these tendons insert together, it would make sense that
they would be contained in a common synovial sheath. All of the other tendons listed have their own synovial sheaths. To visualize these
concepts, see Netter 453.
7. The signs and symptoms of carpal tunnel syndrome may vary among patients, but they always result from compression of
what structure in the carpal canal?
Median nerve
Radial artery
Superficial radial nerve
Ulnar artery
Ulnar nerve

The correct answer is:

Median nerve

Carpal tunnel syndrome is caused by a compression of the median nerve within the carpal tunnel. The carpal tunnel is a canal on the anterior
side of the wrist. It is made of the carpal bones which are covered by the flexor retinaculum. It contains the tendon of flexor pollicislongus,
the tendons of flexor digitorumsuperficialis and profundus, and the median nerve. If the sheath over the common flexor tendons, the ulnar

bursa, becomes inflamed, this can compress the median nerve in the canal, leading to pain and weakness in the hand. None of the other
structures mentioned in the question are contained in the carpal tunnel, so they would not be compressed in that space.
8. What muscle tendon is enclosed within its own synovial sheath in the carpal canal?
Flexor carpi ulnaris
Flexor digitorumprofundus to 2nd digit
Flexor digitorumsuperficialis to 2nd digit
Flexor pollicislongus
Palmaris longus

The correct answer is:

flexor pollicislongus

Flexor pollicislongus is enclosed in its own synovial sheath in the carpal canal, called the radial bursa. The tendons from flexor
digitorumprofundus and flexor digitorumsuperficialis are all contained in a common synovial sheath, called the ulnar bursa. The ulnar bursa
and radial bursa are both in the carpal tunnel, along with the median nerve. (Are you getting the idea that you really need to know about the
carpal tunnel?!) Flexor carpi ulnaris and palmarislongus are not located in the carpal tunnel.
9. The point of insertion of the flexor digitorumsuperficialis tendon to the index finger is on the:
Distal phalanx
Middle phalanx
Proximal phalanx
Second metacarpal
Trapezoid bone

The correct answer is:

middle phalanx

The flexor digitorumsuperficialis tendon inserts on the middle phalanx of fingers 2-5; the flexor digitorumprofundus tendon inserts on the
base of the distal phalanx of fingers 2-5. Both muscles flex the metacarpophalangeal and proximal interphalangeal joints, but flexor
digitorumprofundus is the only muscle that flexes the distal interphalangeal joints.
10.In order to evaluate the carpal-metacarpal joint of the thumb, the median nerve must be deadened at the wrist (causing
paralysis of the muscles supplied by it distal to the injection) to test the joint. Which movement of the thumb would be
most affected by the anesthetic?
Abduction
Adduction
Extension
Flexion
Opposition

The correct answer is:

opposition

If the median nerve was deadened at the wrist, a patient would lose the use of the thenar compartment of the hand. Abductor pollicisbrevis,
flexor pollicisbrevis, and opponenspollicis would be paralyzed. Opponens is the only muscle that allows for opposition of the thumb, so a
patient would no longer be able to oppose the thumb to the fingers. Although abductor pollicisbrevis would be paralyzed, abductor
pollicislongus would still be functional and the patient could still abduct the thumb. Adductor pollicis is in the adductor compartment, and it is
innervated by the deep branch of the ulnar nerve. This means that adduction would not be affected by deadening the median nerve. Extensor
pollicisbrevis and longus are innervated by the deep radial nerve, so extension would still be intact. Although flexor pollicisbrevis would be
denervated, flexor pollicislongus could still flex the thumb. It is a muscle of the forearm which is innervated by the median nerve proximal to
the site of the anesthesia.

11.What arterial vessel accompanies the deep branch of the ulnar nerve across the palm?
Deep palmar arterial arch
Radial
Radialisindicis
Superficial palmar arterial arch
Ulnar

The correct answer is:

deep palmar arterial arch

The deep palmar arterial arch is made by the radial artery and the deep branch of the ulnar artery. It runs deep in the hand, along with the deep
ulnar nerve which innervates the intrinsic muscles of the hand. Although the radial artery contributes to the deep palmar arterial arch, it does
not run with the deep branch of the ulnar nerve. Radialisindicis is a branch of the radial artery that runs up the radial side of the index finger,
similar to a proper digital artery. The superficial palmar arterial arch is made of the ulnar artery and a superficial branch of the radial artery.
Because it is located close to the surface of the hand, it is not related to deeper structures like the deep branch of the ulnar nerve.
12.The fourth dorsal interosseous muscle is innervated by the:
deep branch of the ulnar nerve
dorsal branch of the ulnar nerve
recurrent (motor) branch of the median nerve
superficial branch of the radial nerve
superficial branch of the ulnar nerve

The correct answer is:

deep branch of the ulnar nerve

The deep branch of the ulnar nerve innervates the intrinsic muscles of the hand (with the exception of the thenar compartment). This includes
the dorsal interosseous muscles, the palmar interosseous muscles, the two lumbrical muscles on the medial side of the hand, and the muscles
to the 5th digit (digitiminimi). The dorsal branch of the ulnar nerve innervates the skin of the dorsal surface of the medial 1.5 digits and the
skin of the medial side of the back of the hand. The recurrent motor branch of the median nerve innervates the thenar compartment. The

superficial branch of the radial nerve provides sensory innervation to the skin on the radial side of the dorsum of the hand, including the radial
3.5 digits. Finally, the superficial branch of the ulnar nerve innervates the skin of the palmar surface of the medial 1.5 digits as well as the skin
of the medial side of the front of the hand.
13.A student is rollerblading on the Diag and while trying to avoid a bicyclist falls heavily on his right wrist. After the fall he
notes severe pain in the anatomical snuff box. Radiological studies reveal a fracture of the bone deep to the snuff box
called the
capitate.
hamate.
lunate.
scaphoid.
trapezium.

The correct answer is:

scaphoid

The scaphoid is the bone found at the floor of the anatomical snuff box. It is in the proximal row of carpals and it is frequently fractured.
Capitate, hamate and trapezium are three carpal bones located in the distal row of carpals. Capitate is the largest carpal bone; it transmits force
from the hand to the lunate and the radius. Hamate has a distinct hook; it is an attachment point for the flexor retinaculum. Trapezium is the
carpal bone that articulates with the metacarpal bone of the thumb, forming a saddle joint. Lunate is in the proximal row of carpal bones,
located next to scaphoid. It articulates with the capitate.

A person carrying a soft drink in their right hand slipped on some ice and the bottle broke in their hand. A shard (jagged piece) of glass entered
the hand and severed all of the tissue from the skin down to the metacarpal bone. The cut extended on the lateral side of the index finger, following
the proximal transverse crease, clear to the proximal portion of the head of the second metacarpal bone. It did not extend over the third metacarpal.
The clinical manifestations were as follows:
1. The subject could not flex any part of the index finger
2. The subject had trouble abducting and adducting the index finger
3. The subject had total anesthesia on the palmar side of the index finger and the dorsal side of the distal part of the same digit
4. There was considerable bleeding from severed vessels
Repair proceeded and required six hours of surgery.
14. Which of the following muscle tendons was NOT involved?

the flexor digitorumprofundus muscle


the flexor digitorumsuperficialis muscle
the first dorsal interosseous muscle
the first lumbrical muscle
the second palmar interosseous muscle
The correct answer is:

the second palmar interosseous muscle

The palmar interosseous muscles adduct the 2nd, 4th, and 5th fingers to the middle finger. So, the second palmar interosseous muscle is found
on the lateral side of the 4th finger, far away from the site of injury. Since the subject cannot flex the index finger, you can assume that the
tendons of flexor digitorumprofundus and superficialis were cut. The first dorsal interosseous muscle is located on the lateral side of the index
finger; given its location (and that the subject has trouble abducting the index finger), it seems that this tendon was damaged. The first
lumbrical muscle is also on the lateral side of the index finger--it was also injured by the cut.

15.Which of the following nerves was most likely cut?


common palmar digital branches of the median nerve
deep branch of the ulnar nerve
dorsal digital branch of the radial nerve
motor (recurrent) branch of the median nerve
proper palmar digital branch of the ulnar nerve

The correct answer is:

Common digital branch of the median nerve

Since the patient has total anesthesia on the palmar side of the index finger, you should know that there has been an injury to a superficial
branch of the median nerve, and most likely to the radial two common palmar digital branches of median. Remember, the median nerve
innervates the radial side of the palm, including the radial 3.5 fingers. So, the only answer that makes sense is common digital branches of the
median nerve. The deep branch of the ulnar nerve travels deep in the hand to innervate the intrinsic muscles of the hand. An injury to this
nerve would cause a greater motor deficit in the hand. Dorsal digital branches of the radial nerve innervate the radial 3.5 fingers on the
dorsum of the hand, but not on the palmar side. The motor branch of the median nerve innervates the thenar compartment. If this nerve was
injured, the most important symptom would be that the patient would no longer be able to oppose her thumb. Finally, the proper digital
branches of the ulnar nerve are found on the dorsal and palmar side of the 1.5 fingers closest to the ulnar side of the hand, which is far from
the injury.
16.The excessive bleeding most likely came from which of the following arteries?
deep palmar arterial arch
princepspollicis artery
radial artery
radialisindicis artery
ulnar artery

The correct answer is:

radialisindicis artery

The radialisindicis artery is the equivalent of a proper digital artery on the lateral side of the index finger, which is the site of the injury. It is a
direct branch of the radial artery. The deep palmar arterial arch is made by the radial artery and the deep branch of the ulnar artery. It is found
deep in the hand, so it's not near the area of injury. Princepspollicis is a branch of the radial artery that provides blood to the thumb; it is
similar to a proper digital artery. Since it supplies blood to the thumb, it would not have been cut along the lateral side of the index finger. The
radial artery and ulnar artery supply blood to the hand through the deep and superficial palmar arterial arches; they do not extend up to the
fingers.
The following description pertains to the following questions:
A patient sustained multiple deep lacerations on the palm of his hand and anterior surface of his wrist. During examination, the physician put a piece
of paper between adjacent surfaces of the patient's index and middle fingers and found him unable to squeeze them together with sufficient force to
hold the paper.
17. What muscles are being tested?

First dorsal and first palmar interosseous muscles


First dorsal and second palmar interosseous muscles
First lumbrical and second dorsal interosseous muscles
Second dorsal and first palmar interosseous muscles
The correct answer is:

second dorsal and first palmar interosseous muscles

When you are thinking about abducting and adducting digits in the hand, remember that the midline extends through the middle digit. So, this
patient is trying to adduct his index finger by pulling it towards the midline and abduct his middle finger by pulling it away from the midline.
This means that the patient is using the palmar interosseous muscle (the adductor) on his index finger and the dorsal interosseous muscle (the
abductor) on his middle finger. So, the patient has damaged the first palmar interosseous muscle and the second dorsal interosseous muscle.
Take a look at Netter 465 for a picture of the dorsal and palmar interosseous muscles and their numbering.

18.The most specific nerve branch to these muscles is the:


Deep branch of the ulnar nerve
Median nerve
Recurrent (motor) branch of the median nerve
Superficial branch of the ulnar nerve
Ulnar nerve

The correct answer is:

deep branch of the ulnar nerve

The deep branch of the ulnar nerve is the specific branch of the ulnar nerve that innervates the intrinsic muscles of the hand, with the
exception of the thenar compartment and the radial two lumbrical muscles. This includes the interossei, which abduct and adduct the fingers.
The median nerve innervates most of the muscles in the anterior compartment of the forearm, with the exception of half of flexor
digitorumprofundus and flexor carpi ulnaris. Both of these muscles are innervated by the ulnar nerve. The recurrent motor branch of the
median nerve innervates the thenar compartment of the hand, including abductor pollicisbrevis, flexor pollicisbrevis, and opponenspollicis.
Finally, the superficial branch of the ulnar nerve provides sensory innervation to the skin on the medial side of the wrist and hand and the
medial 1.5 digits on the palmar side of the hand.
19.Bleeding from a superficial cut in the middle of the palm of the hand near the proximal transverse crease comes mainly
from what vessel?
Princepspollicis artery
Radial artery
Radialisindicis artery
Superficial palmar arch
Ulnar artery

The correct answer is:

Superficial palmar arch

The superficial palmar arch is a superficial arterial arch found on the palm of the hand--it is mostly formed by the ulnar artery, but it is
completed by the superficial branch of the radial artery. This arch crosses along the palm of the hand, so a cut in the middle of the palm would
be likely to disrupt this vessel. Princepspollicis is a branch of the radial artery--it supplies blood to the thumb, and is similar in function to a
proper digital artery. The radial artery is a major artery supplying the forearm--in the hand, the radial artery is the primary source of blood to
the deep palmar arterial arch. Radialisindicis is a branch of the radial artery that supplies blood to the radial side of the index finger. Finally,
the ulnar artery is the other major artery of the forearm--it is the artery that supplies the blood to the superficial palmar arch.
20.A deep puncture wound in the palmar surface of the little finger near the proximal IP joint might introduce infection into
which synovial cavity:
Bursa of flexor carpi ulnaris
Fibrous digital sheath of fingers
Intercarpal joint space
Radial bursa
Ulnar bursa

The correct answer is:

Ulnar bursa

The ulnar bursa is a synovial sheath covering the digital flexor tendons--it covers the flexor tendons as they pass under the flexor retinaculum
and terminates near the center of the palm for the second, third, and fourth fingers. However, the portion of the ulnar bursa which is concerned
with the fifth finger does not terminate in the middle of the palm--instead, it continues all the way into the insertion of the profundus tendon
into the fifth digital phalanx. This means that a superficial cut on the palmar side of the fifth digit can introduce an infection into the ulnar
bursa. The radial bursa is the other bursa associated with the flexor tendons--it is a synovial sheath for flexor pollicislongus that extends to the
point where this tendon inserts on the distal phalanx of the thumb. A superficial cut on the palmar side of the thumb might introduce an
infection into the radial bursa. See Netter Plate 446 to get a good idea of these bursae
Flexor carpi ulnaris inserts on the pisiform, hamate, and the fifth metacarpal--so, the bursa associated with this tendon would not be found
near the digits. The fibrous digital sheath of the fingers covers the ulnar bursa and the flexor tendons--these sheaths hold the tendons on the
fingers. The intercarpal joint space is the space between the carpal bones.

21.In carpal tunnel syndrome, compression of the median nerve in the carpal tunnel affects which hand muscle?
Adductor pollicis
Second palmar interosseus
Opponensdigitiminimi
Flexor pollicisbrevis

The correct answer is:

Flexor pollicisbrevis

The recurrent branch of the median nerve innervates the thenar compartment, including abductor pollicisbrevis, flexor pollicisbrevis, and
opponenspollicis. If the median nerve was damaged, any of these muscles might be denervated. Adductor pollicis, the palmar interosseus
muscles, and opponensdigitiminimi are all innervated by the deep branch of the ulnar nerve.
22.After suffering a cut deep to the hypothenar eminence, the patient is unable to hold a sheet of paper between the second
and third digits. The nerve most likely injured was the:
Deep radial
Deep ulnar
Recurrent (motor) branch of median
Superficial radial

The correct answer is:

Deep ulnar nerve

To hold the piece of paper between the second and third digits, this patient needs to abduct the middle finger (pull it away from the midline)
and adduct the second finger (pull it towards the midline). So, the patient wants to use the palmar interosseous muscles to adduct the second
finger and the dorsal interosseous muscles to abduct the third finger. Both of these sets of muscles are innervated by the deep ulnar nerve, so
that must be the nerve that was injured. The deep radial nerve is a branch of the radial nerve to innervates the extensor compartment of the
arm. The recurrent branch of the median nerve innervates the thenar compartment of the hand; the superficial radial nerve provides cutaneous
innervation to the lateral 3.5 fingers on the dorsal side of the hand.

Remember--the deep ulnar nerve innervates all the muscles in the hand, except for the thenar compartment and the first two lumbricals. Those
muscles are innervated by the median nerve!
23.What movement of the thumb would be most affected by lesion of the median nerve in the cubital fossa:
Flexion
Abduction
Adduction
Extension

The correct answer is:

Flexion

If the median nerve was injured in the cubital fossa, all the muscles innervated by the median nerve which are found distal to the cubital fossa
would be injured. The thenar compartment of the hand and the flexor muscles of the forearm would be denervated (with the exception of
flexor carpi ulnaris and the ulnar half of flexor digitorumprofundus--both of these muscles are innervated by the ulnar nerve). This means that
none of the muscles which allow for flexion of the thumb would be intact. Flexor pollicisbrevis is innervated by the recurrent branch of the
median nerve and flexor pollicislongus is innervated by the median nerve. Both of these muscles would be denervated. Abduction is
performed by abductor pollicislongus (innervated by the radial nerve) and abductor pollicisbrevis (innervated by the median nerve). So,
abduction might be weakened, but it would not be completely lost following damage to the median nerve. Adduction is performed by
adductor pollicis, which is a muscle in the medial compartment of the hand, innervated by the deep ulnar nerve. Extending the thumb is
accomplished by extensor pollicislongus and brevis, which are both innervated by the deep radial nerve.
24.Structures within the carpal tunnel include:
Radial bursa
Ulnar nerve
Palmar aponeurosis
Superficial palmar arterial arch
Adductor pollicis muscle

The correct answer is:

Radial bursa

The flexor retinaculum spans between the carpal bones to make the carpal tunnel. The contents of the carpal tunnel are: the tendons of flexor
digitorumsuperficialis and flexor digitorumprofundus (all contained in the ulnar bursa); the tendon of flexor pollicislongus (contained in the
radial bursa) and the median nerve. So, the radial bursa is the only listed structure that is found in the carpal tunnel. The ulnar nerve is
superficial to the flexor retinaculum - it's not in the carpal tunnel. The palmar aponeurosis and superficial palmar arterial arch are found on the
superficial surface of the palm of the hand--they are not structures found at the wrist. Adductor pollicis is a muscle in the adductorinterosseous compartment of the hand - it is not found near the wrist.