Table Of ContentContents
Preface v
Acknowledgements vii
Contributors xiii
Section 1 BaSic PrinciPleS
Chapter 1
Anatomy of the upper limb 3
Shady A. Rehim, Kevin C. Chung
Chapter 2
Objective evaluation of hand function 17
Jeanne M. Riggs, Kevin C. Chung
Chapter 3
Radiologic studies used in evaluation of the upper extremity 21
Aviram M. Giladi, Yirong Wang, Kevin C. Chung
Chapter 4
Electrodiagnostic studies and peripheral nerve ultrasound 33
Kay WP. Ng, Aravinda K. Therimadasamy,
Li Sihui Eileen, Einar P. Wilder-Smith
Chapter 5
Use of locoregional anesthesia and tourniquet in the upper limb 45
Shady A. Rehim, Kevin C. Chung
Chapter 6
Surgical instrumentation and magnification 53
Keming Wang, Evan J. Kowalski, Kevin C. Chung
Chapter 7
Rehabilitation 59
Jeanne M. Riggs, Kevin C. Chung
Section 2 emergency hand Surgery
Chapter 8
Examination of the traumatized hand 69
Shady A. Rehim, Kevin C. Chung
Chapter 9
Compartment syndrome 77
Matthew D. Chetta, Kevin C. Chung
Chapter 10
Acute hand infections 83
Jennifer F. Waljee, Kevin C. Chung
ix
Chapter 11
Nail bed injuries 93
Aviram M. Giladi, Sandeep J. Sebastin, Kevin C. Chung
Chapter 12
Tendon injuries 99
12.1 Flexor tendon injuries
Alphonsus Chong
12.2 Extensor tendon injuries
Teemu Karjalainen
12.3 Rehabilitation of tendon injuries
Erika D. Sears, Kevin C. Chung
Chapter 13
Fractures and dislocations 117
13.1 Principles of skeletal fixation for the hand
Amitabha Lahiri
13.2 Phalangeal fractures and interphalangeal joint dislocations
Maneesh Singhal, Kevin C. Chung
13.3 Metacarpal fractures
Keming Wang, Evan J. Kowalski, Kevin C. Chung
13.4 Ligamentous instability and carpal fractures
Yeong-Pin Peng
13.5 Fractures and dislocations of the distal radius and the distal radioulnar joint
Yeong-Pin Peng
13.6 Therapy for fractures and dislocations in the hand
Kris Tong DL
Chapter 14
Burns 163
Keming Wang, Evan J. Kowalski, Kevin C. Chung
Chapter 15
High-pressure jet injection injuries 175
Keming Wang, Evan J. Kowalski, Kevin C. Chung
Chapter 16
Fundamental principles of microsurgery and replantation 179
Aaron WT. Gan, Yeong-Pin Peng
Chapter 17
Soft tissue coverage and thumb reconstruction 185
Keming Wang, Evan J. Kowalski, Kevin C. Chung
Chapter 18
Approach to complex hand trauma 209
Amitabha Lahiri
Section 3 elective hand Surgery
Chapter 19
System-specific examination of the hand 217
Shady A. Rehim, Kevin C. Chung
Chapter 20
Congenital disorders 227
Alphonsus Chong
x
Chapter 21
Chronic infections of the hand and upper extremity 235
Oluseyi Aliu, Kevin C. Chung
Chapter 22
Tendinopathy and work-related upper-limb disorders 245
Yirong Wang, Evan J. Kowalski, Kevin C. Chung
Chapter 23
Nerve disorders 255
23.1 Nerve injury and repair
Ellen Y. Lee, Aymeric Lim
23.2 Nerve compression syndromes
Ellen Y. Lee, Aymeric Lim
23.3 Nerve palsy
Ellen Y. Lee, Aymeric Lim
23.4 Neonatal brachial plexus palsy
Ellen Y. Lee, Sandeep J. Sebastin, Aymeric Lim
23.5 The spastic upper limb and tetraplegia
Ter Chyan Tan
23.6 Thoracic outlet syndrome
Martins Kapickis
Chapter 24
Vascular disorders of the hand 293
Yirong Wang, Evan J. Kowalski, Kevin C. Chung
Chapter 25
Degenerative osteoarthritis and inflammatory arthritis
of the hand and wrist 305
Jennifer F. Waljee, Kevin C. Chung
Chapter 26
Hand tumors 325
Mark Puhaindran
Chapter 27
Contracture 331
27.1 The stiff digit
Shady A. Rehim, Kevin C. Chung
27.2 Volkmann ischemic contracture
Hari Venkatramani, Praveen Bhardwaj
27.3 Dupuytren contracture
Teemu Karjalainen
Chapter 28
Complex regional pain syndrome 349
Sandeep J. Sebastin
Index 355
xi
Part 1. Basic principles
Table of Contents
Chapter 1. Anatomy of the upper limb ................................................................................................... 3
INTRODUCTION ....................................................................................................................... 3
TERMINOLOGY....................................................................................................................... 3
Palmar/volar surface ............................................................................................................ 4
Dorsal surface .................................................................................................................... 4
Radial and ulnar borders ...................................................................................................... 4
Abduction and adduction ..................................................................................................... 4
Flexion and extension .......................................................................................................... 4
Pronosupination.................................................................................................................. 4
EXTERNAL ANATOMY OF THE HAND .................................................................................... 4
Skin and hand creases ......................................................................................................... 4
Arches of the hand .............................................................................................................. 5
Surface landmarks............................................................................................................... 6
INTERNAL ANATOMY OF THE HAND ..................................................................................... 9
Palmar aponeurosis (PA, Figure 1.5) ...................................................................................... 9
Carpal tunnel (Figure 1.7) .................................................................................................. 11
Guyon canal..................................................................................................................... 12
Digital flexor sheath and pulley system ................................................................................. 12
Extensor tendons............................................................................................................... 14
Intrinsic muscles (Figures 1.14 and 1.15) .............................................................................. 20
Skeletal framework of the hand ........................................................................................... 22
Blood supply of the hand ................................................................................................... 24
Nerve supply of the hand ................................................................................................... 25
ANATOMY OF THE FOREARM ............................................................................................... 29
ANATOMY OF THE ARM ....................................................................................................... 33
2
Chapter 1. Anatomy of the upper limb
A. Rehim, Shady
C. Chung Kevin
INTRODUCTION
The upper limb, especially the hand, consists of multiple structures that together form a unique and versatile part
of the body. To have a better understanding of the pathologic conditions compromising the function of the upper
extremity, it is essential to have a detailed and in-depth appreciation of the normal patterns and functions of the
anatomic constituents of the hand and the upper limb. In this chapter, we will discuss the relevant surface anatomy,
skeletal framework, articular, musculotendinous, vascular, and nervous systems of the upper limb, with a particular
emphasis on the anatomy of the hand.
TERMINOLOGY
First, it is important to be familiarized with the general terms and phrases used to describe joints movement, as
well as the anatomic and topographic features of the upper limb. The use of a standardized terminology facilitates
communication and avoids confusion between hand surgeons and between surgeons and other health-care professionals
when describing upper limb pathology (Figure 1.1 a and b).
Figure 1.1. (a) Normal range of motion of the hand and forearm. Standard nomenclature
and palmar surface of the palm.
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Anatomy of the upper limb
Palmar/volar surface
This is the anterior surface of the hand, incorporating thick glabrous (hairless) skin with noticeable skin creases over
the palm and fingers. More proximal, the anterior surface of the wrist and the forearm is known as the volar surface.
Dorsal surface
This is the posterior surface of the hand and forearm. In the hand, the dorsal surface is covered with thin mobile skin
containing hair follicles.
Radial and ulnar borders
The radial border of the hand/upper limb is the side that is furthest away from the midline of the body containing the
thumb, whereas the ulnar border of the hand/upper limb is the side closest to the midline and contains the small finger.
Abduction and adduction
Abduction is moving a body part away from the midline, whereas adduction is the opposite and means moving toward
the midline. In the hand, the long finger is considered the midline of the hand, and therefore, finger abduction is
spreading the fingers away from the long finger, whereas finger adduction is bringing the fingers together toward the
long finger.
Flexion and extension
By definition, flexion is a bending movement that decreases the angle between two body parts, whereas extension is a
straightening movement that increases the angle between body parts (e.g. wrist joint flexion and extension movements).
Pronosupination
This describes the inward (pronation) and outward (supination) rotation of a joint along its longitudinal axis, and is
often used to describe the rotatory movement of the forearm at the proximal and distal radioulnar joints (DRUJs)
(Figure 1.1 a).
EXTERNAL ANATOMY OF THE HAND
Skin and hand creases
Each hand consists of five rays/digits (standard nomenclature: thumb, index, long, ring, and small fingers), a palmar
and a dorsal surface, attached proximally to the wrist joint, and is covered by a specialized skin envelope. Besides being
a protective layer against infections and other types of injuries, the skin coverage of the hand has a remarkable ability
of functional adaptation, and one of its major roles is enhancing the prehensile ability of the hand when executing
daily activities.
The palmar and dorsal skin of the hand is functionally and anatomically different, each serving a specific purpose.
On the palm, the skin is composed of thick keratinized papillary squamous epithelium that helps it withstand the
shearing forces resulting from daily use of the hand. The dorsal skin is supple, thin, and mobile to allow the unrestricted
movement of the underlying joints. By looking on the palm, one can see three distinct types of skin lines (Figure 1.1 b).
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Anatomy of the upper limb
• Thick skin creases: Seen over the wrist joint (proximal and distal wrist creases), the palm (three palmar skin creases),
and over the metacarpophalangeal (MCP) and interphalangeal (IP) joints of the fingers. These skin creases are
tethered to the deep fascia, which stabilize the palmar skin and prevent skin gliding over the hand when handling
objects. Additionally, these skin creases are sometimes referred to as the skin joints or folds; this is clinically
important, because if a flexion crease is absent, this means that the underlying joint has not been moving, often seen
in congenital conditions such as arthrogryposis when the joints are not developed normally.
A fine network of prominent skin folds known as the papillary ridges. The skin papillary ridges serve two important
functions: first a tactile function (sense of touch) and second a mechanical function. A moist palm due to secretion
of sweat together with these papillary ridges creates a friction coefficient that prevents slipping of objects during
prehension. Tension skin lines, also known as Langer lines. It is postulated that along these lines, skin incisions would
result in the least amount of scarring when the skin is closed by primary intention.
Underneath the skin is a layer of a fatty tissue, which is divided into fat lobules by fibrous septa extending from the
skin to the deep fascia. This creates areas of prominent fat pads that are most noticeable over the hypothenar muscles,
thenar muscles, the metacarpal arch, and over the fingers in between joint creases. The fat cushions/pads protect the
hands against external forces and allow the hands to conform nicely around objects of various shapes, thus improving
the act of prehension.
On the dorsum of the hand, the skin is thin owing to the much thinner dermis and epidermis as well as the lack of fat
pads, when compared with the palmar skin. Additionally, the dorsal skin is very mobile due to the loose attachment it
has with the deeper tissue. In spite of this great mobility, the skin on dorsum of the hand becomes maximally stretched
when making a fist. It is important to realize this limitation when reconstructing soft tissue defects over the dorsum
of the hand, as solely relying on skin mobility may not be sufficient to cover or reconstruct wound defects over the
dorsum of the hand.
Arches of the hand
When the forearm is supinated and the hand is resting on a flat surface, a concavity is seen on the palmar surface of
the hand. Three arches form the shape of this concavity: (1) The proximal transverse arch; (2) longitudinal arch(s);
and (3) distal transverse arch, spanning the palmar surface of the hand (Figure 1.2).
1. Proximal transverse (carpal arch): A concave curvature formed at the level of distal carpal row. The keystone (apex
of the arch that bears maximum force) of this arch is the capitate bone
2. Longitudinal arch(s): a carpometacarpophalangeal arch(s) that extends from the crease of the wrist through the four
digital rays. The keystone of this arch is the MCP joint
3. Distal transverse (metacarpal arch): A concave curvature formed at the metacarpal heads of the index, long, ring,
and small fingers. The keystone of this arch is the head of the 3rd metacarpal bone
The longitudinal and distal transverse arches of the hand are mobile, whereas the proximal transverse arch is fixed/
nonmobile. The mobility of these arches further deepens the concavity of the palm to accommodate for objects of
different sizes (e.g. holding a ball using one hand, Figure 1.2). Besides the skeletal framework described above, the
curvature of the palm is also maintained by the functional tone of intact intrinsic muscles. Thus, conditions that result
in intrinsic muscle paralysis such as ulnar nerve palsy would consequently alter the shape of the hand due to the loss of
the muscular tone. Another muscle is the palmaris brevis, which is innervated by the ulnar nerve. The palmaris brevis
muscle arises from the transverse carpal ligament (TCL) and palmar aponeurosis (PA) and inserts superficially into
the dermis of the skin. Contraction of this muscle results in cupping of the palm when grasping an object or drinking
using the hands.
5
Anatomy of the upper limb
Figure 1.2. (a) Arches of the hand. (b) Mobility of the arches of the hand allows us to handle
larger objects.
Surface landmarks
Knowledge of the surface anatomy is essential in the examination of the hand and for planning surgical incisions to
avoid iatrogenic injuries of deep vital structures. On the palmar aspect of the hand, one can identify the approximate
location of deeper structures using the Kaplan cardinal line. Although several definitions exist, Kaplan described the
cardinal line as a line drawn from the junction of the MCP joint line of the thumb at the first interdigital fold to a point
6
Anatomy of the upper limb
2 cm distal to the pisiform. The proximal intersection of perpendicular lines drawn from the ulnar and radial borders
of the long and ring fingers with Kaplan line provide an estimated location of the important structures of the hand
(Figure 1.3). There is no general consensus on the accurate location of these structures; however, the following are
useful measurements to identify pertinent deep structures of the hand based on the above description:
Figure 1.3. Kaplan cardinal line and its anatomical relationship to pertinent deep structures
of the hand.
1. Scaphoid tubercle: Palpable at the distal wrist crease just radial to the tendon of the flexor carpi radialis (FCR)
muscle
2. Pisiform: Palpable at the distal wrist crease on the ulnar side at the insertion of the flexor carpi ulnaris (FCU) muscle
3. Hook of hamate: Located approximately 1 cm distal and slightly radial to the pisiform bone
4. Motor branch of ulnar nerve: Located midway between the pisiform and hook of hamate lying deep in the Guyon
canal
7
