Table Of ContentSURGICAL ANATOMY OF THE
HAND AND UPPER EXTREMITY
SURGICAL ANATOMY OF THE
HAND AND UPPER EXTREMITY
JAMES R. DOYLE, M.D.
Emeritus Professor of Surgery (Orthopaedics)
John A. Burns School of Medicine
University of Hawaii
Honolulu, Hawaii
Editor-in-Chief
The Journal of Techniques in Hand
and Upper Extremity Surgery
MICHAEL J. BOTTE, M.D.
Co-Director
Hand and Microsurgery Service
Division of Orthopaedic Surgery
Scripps Clinic
La Jolla, California
Orthopaedic Surgery Service
San Diego VA Health Care System
Clinical Professor
Department of Orthopaedic Surgery
University of California, San Diego
School of Medicine
San Diego,California
Illustrated by Elizabeth Roselius
with contributions by Christy Krames
Acquisitions Editor: Robert Hurley
Developmental Editor: Keith Donnellan
Production Editor: Thomas J. Foley
Manufacturing Manager: Benjamin Rivera
Cover Designer: Christine Jenny
Compositor:Lippincott Williams & Wilkins Desktop Division
©2003 by LIPPINCOTT WILLIAMS &WILKINS
530 Walnut Street
Philadelphia, PA 19106 USA
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Library of Congress Cataloging-in-Publication Data
Doyle, James R.
Surgical anatomy of the hand and upper extremity / James R. Doyle and Michael J. Botte.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-397-51725-4
1. Hand—Anatomy. 2. Arm—Anatomy. I. Botte, Michael J. II. Title.
[DNLM: 1. Arm—anatomy & histology. 2. Hand—anatomy & histology. WE 805
D754s 2003]
QM 548 .D69 2003
611′.97—dc21
2002030007
Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. However, the authors and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, expressed or implied,
with respect to the currency, completeness, or accuracy of the contents of the publication. Application of
this information in a particular situation remains the professional responsibility of the practitioner.
The authors and publisher have exerted every effort to ensure that drug selection and dosage set forth in
this text are in accordance with current recommendations and practice at the time of publication. However,
in view of ongoing research, changes in government regulations, and the constant flow of information
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for any change in indications and dosage and for added warnings and precautions. This is particularly
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Some drugs and medical devices presented in this publication have Food and Drug Administration
(FDA)clearance for limited use in restricted research settings. It is the responsibility of the health care
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10 9 8 7 6 5 4 3 2 1
To Julie Kaye Frances and Robert E. Carroll, M.D., friends and mentors.
J.R.D.
To my mother, Verona Louise Minning-Botte, M.D., and
my father, Joseph Michael Botte, M.D.
For their love, encouragement, and support
and for being the best teachers that I ever had.
M.J.B.
CONTENTS
Contributing Authors ix
SECTION II: REGIONAL ANATOMY 295
Foreword by David P. Green xi
Preface xiii
5 Brachial Plexus 297
Vincent R. Hentz and Y. Mark Hong
SECTION I: SYSTEMS ANATOMY 1 6 Arm 315
7 Elbow 365
1 Skeletal Anatomy 3
8 Forearm
2 Muscle Anatomy 92
Part 1: Flexor Forearm 407
Appendix 2.1. Muscles of the Hand and Forearm
and Arm: Origin, Insertion, Action, and Part 2: Extensor Forearm 461
Innervation 180
9 Wrist 486
Appendix 2.2. Muscle Compartments and Fascial Richard A. Berger, James R. Doyle, and Michael J. Botte
Spaces of the Upper Extremity 183
10 Hand
Appendix 2.3. Human Forearm Muscle Difference
Index Values: A Comparison of Architectural Part 1: Palmar Hand 532
Features of Selected Skeletal Muscles of the Upper
Part 2: Dorsal Hand 642
Extremity 184
3 NerveAnatomy 185
Appendix: Anatomic Signs, Syndromes, Tests, and
Appendix 3.1. Dermatomes of the Upper
Eponyms 667
Extremity 226
4 Vascular Systems 237 Subject Index 693
CONTRIBUTING AUTHORS
Richard A. Berger, M.D., Ph.D. Professor, Departments of Anatomy and Orthopaedic
Surgery, Mayo Clinic, Rochester, Minnesota
Vincent R. Hentz, M.D. Chief, Hand Division, and Professor of Functional Restora-
tion (Hand), Department of Surgery, Stanford University School of Medicine, Palo
Alto, California
Y. Mark Hong, B.S. Department of Surgery, Stanford University School of Medicine,
Palo Alto, California
FOREWORD
The best surgeons are those well versed in anatomy. A sur- Another pleasant surprise in this text is the appendix of
geon can never learn too much anatomy, but up until now, anatomic signs, syndromes, tests, and eponyms, where even
he or she had to go to many sources to glean a broad base of the surgeon who has studied the history of surgery will find
anatomical knowledge. My own career illustrates this point. new or more accurate information. Practical lessons in the
As a medical student, I began with Gray’s massive and dry Greek and Latin derivations of words explain why similar-
tome, learning anatomy for the sake of anatomy, with no sounding words that evolve from separate sources have dif-
clinical relevance. Then, as a resident, I discovered ferent meanings.
Hollinshead’s three-volume text that added functional impli- One of the authors, James R. Doyle, was the first to
cations. I also found, at that time, Henry’s classic book with describe in detail the flexor pulley system in the fingers
its quaint Irish-English prose and manual mnemonics. As a (1975) and later in the thumb (1977). Jim Doyle has stud-
young surgeon, I sought out books that would give me quick, ied the anatomy of the hand throughout his entire profes-
snapshot glimpses of anatomy that I could memorize and sional career with the eye of an artist who can perceive
carry in my head at least until the next day in the operating details better than most of us, with an inherent tenacity fired
room. Grant’s Atlas was the first of these, which was later even harder during a fellowship year with Robert E. Carroll,
replaced on my shelf by McMinn and Hutchings’ magnifi- and with an exquisite and careful attention to detail. This
cent atlas with its lifelike-quality color plates. Specialized texts book is the culmination of his life-long dedication.
such as Sunderland and Spinner have described wonderfully Michael Botte, his co-author, brings to this project the
detailed and precise anatomy, but with a limited focus. thoroughness and precision of a true scientist, and his input
Now the hand and upper extremity surgeon has what all is significant. The collaboration of Doyle and Botte has pro-
of the aboveresources offered and more, packed into a sin- duced a remarkable piece of workthat will benefit not only
gle volume. The thoroughness of Gray, the practical appli- the entire surgical community, but our patients as well.
cations of Hollinshead, and the clarity of McMinn and Every serious hand surgeon will find a readily accessible
Hutchings havebeen blended into one unified source. spot on his or her bookshelf for this text.
More than sixty crisp photographic prints depict
detailed cadaver anatomy with a precision and clarity that David P. Green, M.D.
rivals McMinn. Most of the drawings were created by Eliz- Clinical Professor
abeth Roselius, a master among contemporary medical Department of Orthopaedics
illustrators. The exceptionally high quality of these illustra- University of Texas Health
tions is complemented by a text that is not only thorough, Science Center at San Antonio
but also replete with clinical applications. San Antonio, Texas
PREFACE
Our goal has been to assemble between two covers a com- will also recognize the immense value of the systems
prehensive collection of anatomical material designed to aid approach, found in the section on Systems Anatomy, in
the hand and upper extremity surgeon in the evaluation and providing a comprehensive and overall view of a given
treatment of patients. A comprehensive knowledge of anatomic structure or system.
anatomy is a major prerequisite for safe and effective The authors take great pride in the color photographs of
surgery. Although written by hand surgeons for hand sur- fresh cadavers used in this text. A quote by Emanuel
geons, the authors believe that this text will also be useful to Kaplan, about color photographs, from his foreword to
hand therapists, anatomists, neurologists, neurosurgeons, Milford’s 1968 classic monograph on Retaining Ligaments of
sports medicine surgeons and physicians, physiatrists, and the Digits of the Handseems appropriate here as well, “The
bioengineers because it is a compendium of anatomic natural color illustrations add precision and eliminate the
knowledge. The science of anatomy and the art of surgical imaginary interpretive creativity leading to error.” We hope
technique are intertwined topics that are not easily sepa- that the quality of our color photography can approach that
rated. Although this book is not designed as a text on oper- of Milford and warrant the affirmation of Kaplan on the
ative surgery, overlap with surgical technique is inevitable, value of natural color photographs. We hope these color
appropriate, and complementary to the goal of the book. photographs, along with the excellent illustrations, will
Although another anatomy textbook may seem redun- serve to make the anatomy in this text as realistic as possi-
dant, we hope the reader will agree that this text represents ble. We also believe that the combination of these two art
aunique and current collection of material, which may not forms along with the descriptive text will provide the reader
be conveniently found elsewhere. Much of the information with appropriate information, which will permit accurate
can be found in other resources such as texts and journals preoperative evaluation, diagnosis, and effective surgical
but wehope the reader, who like us has had difficulty recall- treatment.
ing wherewefound a particular bit of information that we Anatomy,as a surgeon must deal with it, is three dimen-
nowneed to reviewor utilizein a timely fashion, will come sional, but only two dimensions can be portrayed in a text.
to value this comprehensive resource. Our primary goal in This fact should immediately indicate to the reader that
this text is to provide a readily available source for this there is no substitute for personal experience in the dissec-
information that is user friendly, easily portable, and clini- tion room. In a two-dimension text, structures are often
cally relevant. portrayed as lying side by side when in reality they may be
We hope that the arrangement, clarity, and brief yet vertically arrayed. A good example is the usual depiction of
comprehensive presentations of these topics will be of suffi- the radial and ulnar arteries in the proximal forearm. The
cient uniqueness to earn the designation of original, but we ulnar artery is depicted as lying to the ulnar side of the
readily admit that paraphrasing and adoption of others’ radial artery in the same anatomic plane whereas, in reality,
original concepts have been used (although we have done the ulnar artery is deep and ulnar to the radial artery and is
our best to givecredit where it was due). The words of Ana- often difficult to find. The reader should also note that the
tole France (passed on to us by Adrian Flatt) bear repetition anatomic variations included are those that the authors per-
here, “When a thing has been said and said well, have no ceive to have some practical clinical relevance to the region
scruples, take it and copy it.” and that the list of variations is not encyclopedic.
The text is divided into sections on Systems Anatomy Reported differences in anatomy may be due to
and Regional Anatomy, followed by an Appendix on anatomic variations as well as inter-observer variability and
Anatomic Eponyms, Signs, Syndromes and Tests. The sec- subsequent interpretation of the observation. It would seem
tion on Regional Anatomy represents the practical compo- reasonable to assume that all observers of a particular region
nent of this text because it provides the reader with or segment of anatomy would see or observe the same
anatomic landmarks, relationships, surgical approaches, things and interpret what they saw in a similar uniform
clinical correlations, and the anatomy of selected anatomic fashion. Such is not the case, and although many points of
variations found in that region. The student of anatomy anatomy are agreed upon there are many that are not. Two
xiv Preface
illustrative examples come readily to mind: (1) the arcade of important and tell us that significant variation exists in that
Struthers’ in the arm and (2) the location of the sesamoid particular structure or region and that the surgeon must be
bones about the MP joint of the thumb. Some authors prepared to encounter such an arrangement or even a new
describe in detail the arcade of Struthers’ 8 cm above the and unreported pattern or arrangement.
medial humeral epicondyle and attach clinical significance By now, the reader has begun to appreciate the fact that
to it as a potential site of ulnar nerve compression in the anatomy is not a “fixed” science, but rather an evolving or
arm. Others claim that it does not exist or at least that they developing endeavor with many remaining challenges and
have never seen it and thus it has no clinical relevance. The opportunities.
location of the ulnar and radial sesamoid bones about the All authors have their own methods for placing thoughts
MP joint of the thumb have been reported to be in the on paper. This quote from Wallace Stegner1, although
adductor pollicis and flexor pollicis brevis tendons respec- directed at the writer of autobiography or fiction, seems
tively or in the palmar plate where they possess articular car- appropriate, “You take something that is important to you,
tilage and articulate with the thumb metacarpal; two something you have brooded about. You try to see it as
entirely different pictures of the same structures. Inter- clearly as you can, and to fix it in a transferable equivalent.
observer variability may be illustrated by the imperfect, yet All you want in the finished print is the clean statement of
humorous, analogy of six blind persons examining a camel. the lens, which is yourself, on the subject that has been
Each of their descriptions are based upon their particular absorbing your attention.”
location about the camel. Their significant inter-observer The authors wish to recognize their debt to those sur-
variation results in a series of descriptions that would con- geons and anatomists who have studied and described their
found even a camel veterinarian. The authors include them- anatomic findings in the upper extremity and to our many
selves in those observers who may be subject to imperfect mentors and colleagues who have taught, encouraged, and
observation as well as faulty interpretation. Thus, there may inspired us.
be a lively correspondence and commentary generated by Finally, the authors wish to acknowledge their debt to
this text. Robert Hurley and Keith Donnellan of the editorial staff at
We believe that studies that have large numbers of spec- Lippincott Williams & Wilkins who have patiently guided
imens in their data base have a greater potential for reflect- and encouraged us throughout this process in such a com-
ing what might be considered more common and thus petent and professional manner. We also owe a great debt to
likely to be encountered in the day to day practice of Elizabeth Roselius, medical artist, for her understanding of
surgery. Studies with small numbers of specimens in which complex anatomic concepts and her ability to convert those
several patterns or categories of anatomical arrangement are concepts into clear and concise drawings.
noted tell us that significant variation exists. Itmay not tell
us the true incidence of a given pattern or arrangement in James R. Doyle, M.D.
spite of the authors’ conscientious reporting of one, two, or Michael J. Botte, M.D.
three cases in their series which demonstrated a particular
1 Stegner WE, Wherethe bluebirdsings to the lemonade springs.New
pattern or arrangement. Such studies though, are still York: Random House, 1992.
S E C T I O N
II
SYSTEMS ANATOMY
