Table Of ContentE X A M IN A T IO N OF T H E
H A N D
A N D W R I S T
RAOUL TUBIANA
, MD, President, Institut de la Main, Paris
JEAN-MICHEL THOMINE,
MD, Professor of
Orthopaedics and Traumatology, University
Hospital, Rouen
EVELYN MAC KIN,
PT Executive Director, Hand
Rehabilitation Foundation, Philadelphia
informa
healthcare
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CONTENTS
List of contributors iv
Foreword v
Preface vii
Acknowledgements viii
Functional Anatomy 1
1.1 Skeleton of the hand 4
1.2 Skeleton of the wrist 28
1.3 Movements of the hand and wrist 40
1.4 Skin cover 128
1.5 Functions of the hand 156
2 Clinical Examination of the Teguments, the Skeleton and the
Musculotendinous Apparatus 175
2.1 Examination of the teguments, palmar aponeurotic lesions
and trophicity 176
2.2 Examination of the bones and joints 185
2.3 Examination of the musculotendinous apparatus 205
3 Imaging 225
3.1 Radiological examination 225
3.2 Investigation of the circulation 243
/* Examination of the Peripheral Nerve Functions in the Upper Limb 261
4.1 Innervation of the upper limb and clinical features of nerve paralysis 262
4.2 Functional assessment of motor function 286
4.3 Sensibility evaluation 328
4.4 Signs of neural regeneration 355
References 371
Index 387
LIST OF CONTRIBUTORS
R Tubiana Institut de la Main, Centre Orthopedique Jouvenet, 6 square
Jouvenet, Paris 75116, France
J-M Thomine Clinique Chirurgicale Orthopedique et Traumatologique, Hopital
Charles Nicolle, Rouen Cedex 76031, France
E J Mackin The Hand Rehabilitation Foundation, 834 Chestnut Street,
G1114, Philadelphia, PA 19107, USA
F Brunelli Institut de la Main, Centre Orthopedique Jouvenet, 6 square
Jouvenet, Paris 75116, France
J P Melki Clinique Bizet, 23 rue Georges Bizet, Paris 75016, France
Ph Saffar Centre Chirurgical de la Main, 5 rue du Dome, Paris 75116,
France
P Seror 146 Avenue Ledru-Rollin, Paris 75011, France
FOREWORD
One would call Raoul Tubiana the grand old man of world hand surgery were it not
for the fact that in spirit and appearance he looks a young man. There is no doubt,
however, that he is one of the outstanding world leaders in the field of hand surgery.
He has pioneered so many different surgical procedures, has written and edited
outstanding and authoritative texts on all aspects of hand surgery, and has created a
world-famous institute for hand surgery in the heart of Paris. His affection and dedica
tion to his trainees is legendary, and as important is his nurturing, stimulation and
encouragement of hand therapists.
Those of us who have dedicated our lives to rehabilitation of the upper limb owe
him a great debt for his example and his encouragement. Successful surgery of the hand
depends vitally on a correct diagnosis and an assessment of the functional capacity of
the hand and to what use the patient wishes to put it when the surgeon has done his
best. It is therefore essential that the budding hand surgeon have a detailed knowledge
of anatomy and physiology, both structural and functional. There are few more compli
cated areas than the hand, and it is a tribute to the brilliance of this text that these
most complex areas are beautifully and simply described and illustrated. Indeed, the
line drawings are a work of art in themselves. One would mention, among many, the
transverse metacarpal tunnel, the transverse fascia and the pulley system of the fingers,
the intrinsic musculature, the ligamentous system of the wrist, the anatomy of the trian
gular fibrocartilage and the spiral organization of the phalanges and joints. These
drawings will not only elucidate some of the complexities of hand anatomy but will
also reveal aspects of function that have been mysterious’ and unknown heretofore or
not widely recognized.
Throughout the text, clinical conditions illustrate the lessons that anatomy has to
teach us. This is particularly true in the case of pathology of Dupuytren’s contracture,
rheumatoid arthritis, and claw hand and ulnar palsy. It is thrilling to see Fibonacci’s
series applied to finger movements. The reader throughout will be enchanted by refer
ences to art and culture. Raoul Tubiana is in the great tradition of the natural philo
sophers; for so designated were the scientists of old who explored nature, revealing its
mysteries with love and fascination and transmitting them down the generations.
Throughout this text Tubiana speculates and thinks with an original mind about the
function of the various parts of the hand. The fact that Tubiana applies his critical
FOREWORD
faculties to the assessment of other writers’ work makes this much more than a text
of anatomy and examination; it embraces the whole field of previous and contempo
rary workers so that one has the feeling of a great family of surgeons and anatomists
exploring the mysteries and delights of the hand.
In the section on clinical examination the reader will find description of all the tests
for different deformities and disorders. One was particularly impressed by the assess
ment of the tests for carpal instability, and for tendon function, and the various
methods for the management of swan neck, mallet finger and the boutonniere finger
which can cause such confusion to the tyro. There is an illuminating chapter on imaging
techniques which contributes so much to better understanding of wrist pathology in
particular. The value of this text is greatly enhanced by the collaboration of an
orthopaedic specialist, Professor Thomine, and of the world-famous hand therapist
Evelyn Mackin. As the author comments in his Preface, this is far more than a new
edition of the original 1984 text; it totally supersedes the earlier work, pioneering and
brilliant as that was. There will be other editions to come, for this is a constantly devel
oping area. New discoveries will be made in the field of functional anatomy and in the
understanding of the pathophysiology of many clinical hand problems. There will be
advances particularly in sensory assessment and sensory rehabilitation as we begin, with
the help of the anatomist and the physiologist, to understand more the complexities of
peripheral and central neural encoding, and one will see more retraining procedures
developed. It is difficult to see how this book can have a rival; impossible to imagine
it being exceeded in its comprehensiveness, the beauty of its illustration and the love
and dedication of the writing that has gone into it.
C B Wynn Parry
vi
PREFACE
This book is much more than a new edition of Examination of the Hand and Upper
Limb (WB Saunders, 1984). Anatomy is a cornerstone of examination of the hand and
wrist, and therefore an important section of this book is devoted to anatomy - not the
static anatomy found in most text books, but functional and surgical anatomy, provid
ing the information needed by surgeons, microsurgeons, physiotherapists, neurologists,
in fact anyone with an interest in the normal anatomy and physiology and the pathol
ogy of the hand and wrist. The section on clinical examination has been divided into
examination of the teguments, skeleton and musculotendinous apparatus. Clinical
examination must be augmented by imaging, which has progressed rapidly, and this is
discussed in the third section of the book. Electrodiagnosis and the other modalities
are described in this edition. Examination of the peripheral nerve function has been
described for the whole upper limb as innervation of the hand cannot be dissociated
from the rest of the limb. It comprises assessment of motor function and evaluation of
sensation and of the clinical features of nerve paralysis.
I wish to thank the authors who have participated in this work, and my friends
Adalbert Kapandji and William Littler for their clear and attractive drawings, and also
Leon Dorn, whose beautiful work has illustrated my books for more than 20 years.
This book contains some text and illustrations taken from the five volumes of The Hand
published by WB Saunders and Masson.
R Tubiana
ACKNOWLEDGEMENTS
Figure 1.40 appears by courtesy of Professor F Bonnel, Laboratoire d’Anatomie,
Montpellier; Figure 3.47 by courtesy of Dr O Judet and Professor L Lacombe, Hopital
A Pare, Paris; Figure 4.24a,b by courtesy of Dr L Mannerfelt.
The following are reproduced with the kind permission of the publishers;
Brand PW, Beach RB, Thomsen DE (1981) Relative tension and potential excursion
of muscles in the forearm and hand, ] Hand Surg, 6:201—9 (Figures 1.47—50);
Hakstian RW, Tubiana R (1967) Ulnar deviation of the fingers, J Bone Joint Surg,
49A:299 (Figure 1.78);
Kapandji A1 (1963) Physiologie articulaire, volume 1 (Librarie Maloine: Paris) (Figure
1.10b).
Lundborg G, Myrhage R, Rydevik B (1977) The vascularization of human flexor
tendons within the digital synovial region - structural and functional aspects, ] Hand
Surg, 11 A:692-6 (Figure 1.88c);
Ochiai N et al (1979) Vascular anatomy of flexor tendons, J Hand Surg, 2: 417 (Figure
1.88a);
Penfield WG, Rasmussen T (1950) The Cerebral Cortex of Man (Macmillan: New York)
(Figure 1.181);
Tubiana R, ed (1981) The Hand, volume 1 (WB Saunders: Philadelphia): from the
chapter by Aubriot (Figure 2.33); Backhouse (Figure 3.30); de la Caffmiere (Figure
2.36); Fahrer (Figures 1.137 and 1.138); Kapandji (Figures 1.124 and 2.19); Pallardy
et al (Figures 3.8, 3.18a and 3.45a); Pieron (Figure 1.125); Rabischong (Figure 1.152);
Thomine (Figures 1.151 and 2.29); Tubiana (Figures 1.37b, 1.69, 1.112, 1.116, 1.119,
1.173); Valentin (Figures 1.103, 1.104, 1.106 and 1.114);
Tubiana R, ed (1985) The Hand, volume 2 (WB Saunders: Philadelphia): from
the chapter by Curtis (Figure 2.39); Gilbert (Figure 1.29); Kuhlmann et al (Figures
1.34, 1.38b, 1.53, 1.56, 1.58); Tubiana (Figures 1.36b, 1.4la, 1.144, 1.146, 1.167,
2.30);
Tubiana R, ed (1988) The Hand, volume 3 (WB Saunders: Philadelphia) from the
chapter by Albertoni (Figure 2.51); Jupiter and Kleinert (Figure 2.9b); Melki (Figure
ACKNOWLEDGEMENTS
3.36); Tubiana (Figures 1.85, 1.86, 1.115, 1.164, 2.37, 2.40, 2.42, 2.43a, 2.44a, 2.45b
and 2.46—49);
Tubiana R, ed (1993) The Hand, volume 4 (WB Saunders: Philadelphia): from the
chapters by Tubiana (Figures 1.60, 1.62, 1.109, 1.110, 1.121b, 1.131-135, 2.27, 2.28
and 4.20-4.22);
Tubiana R, Malek R (1968) Paralysis of the intrinsic muscles of the fingers, Surg Clin
North Am, 48:1140 (Figure 1.111);
Tubiana R, McCullough CJ, Masquelet AC (1990) An Atlas of Surgical Exposures of the
Upper Extremity (Martin Dunitz and JB Lippincott: London and Philadelphia) (Figures
1.12b, 1.13c, 1.20, 1.21, 1.42b, 1.43, 1.92, 1.159-162, 1.166, 2.7, 2.8, 2.35, 2.38,
3.31-35, 3.45, 3.46, 4.2, 4.15).
Tables 1.2 and 1.3 originally appeared in Brand PW, Beach RB, Thomsen DE (1981)
Relative tension and potential excursion of muscles in the forearm and hand, J Hand
Surg, 6:201-9.
Table 1.6 originally appeared in Kelleher JC, Robinson JH, Yanik MA (1985) The
pattern abdominal pedicle flap. In: Tubiana R, ed, The Hand, volume 2 (WB Saunders:
Philadelphia).
Portions of Section 4.4 have appeared in Tubiana R, Nerve regeneration and prognosis
following peripheral nerve injury. In: Tubiana R, ed, The Hand, volume 3 (WB
Saunders: Philadelphia).
The following are redrawn with the kind permission of the publishers:
Capener N (1956) The hand in surgery, J Bone Joint Surg, 38B:128 (Figure 1.61 b);
Cauna M (1954) Nature and functions of the papillary ridges of the digital skin, Anat
Rec, 119:449 (Figure 1.154);
Hagert CG (1992) The distal radioulnar joint in relation to the whole forearm, Clin
Orthopaedics, 275:56—64 (Figure 1.52);
Kapandji Al (1963) Physiologie articulaire, volume 1 (Librarie Maloine: Paris) (Figures
1.51, 1.55a, b);
Kelleher JC (1982) Large combined axial vessel pattern abdominal pedicle flap, Am J
Anesthesiol, 11:33-48 (Figure 1.165);
Kuczynski K (1974) Functional micro-anatomy of the peripheral nerve trunks, Hand,
6:1-10 (Figure 1.124);
Lundborg G, Myrhage R (1977) The vascularization and structure of the human digital
tendon sheath, Scand J Plast Reconstr Surg, 11:195-203 (Figure 1.89);
Martineaud JP, Seroussi S (1977) Physiologie de la circulation cutanee (Masson: Paris)
(Figure 1.145);
Rabischong P (1963) Innervation proprioceptive des muscles lombricaux de la main
chez l’homme, Rev Chir Orthop, 25'.927 (Figure 1.168);
ix
ACKNOWLEDGEMENTS
Stack GH (1962) Muscle function in the fingers, J Bone Joint Surg, 44B:899—909
(Figure 1.120);
Stack GH, Vaughan-Jackson OJ (1971) The zig-zag deformity in the rheumatoid hand,
Hand, 3: 62-7 (Figure 1.61a);
Tubiana R, ed (1981) The Hand, volume 1 (WB Saunders: Philadelphia): from the
chapter by Dubousset (Figures 1.73b, 1.74, 1.79); Fahrer (Figure 1.136);
Tubiana R, ed (1985) The Hand, volume 2 (WB Saunders: Philadelphia): from the
chapter by Tubiana (Figure 2.18); Weber (Figure 1.57);
Tubiana R, ed (1993) The Hand, volume 4 (WB Saunders: Philadelphia): from the
chapter by Narakas (Figure 4.1c); Tubiana (Figure 4.24c);
Wynn Parry CB (1981) Rehabilitation of the Hand, 4th edn (Butterworth: London)
(Figure 4.91);
Zancolli E (1979) Structural and Dynamic Basis of Hand Surgery, 3rd edn (JB
Lippincott: Philadelphia) (Figure 1.82).
Evelyn Mackin would like to thank Teri Stahller for her excellent photographic assis
tance, and Kathryn Maynes for her excellent secretarial assistance, in the preparation of
Section 4.3.
x
