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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_801_Библиотеки_им_академика_М_И_Перельмана
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Anatomical snuff-box: A depression at the dorsal end of
the radius can be seen when the thumb abducts and extends,
whose lateral boundary is tendon of extensor pollicis brevis
and tendon of abductor pollicis longus, the medial boundary
is tendon of extensor pollicis longus, and the fossa base is the
scaphoid bone, trapezium bone and the base of the rst metacarpal bone. Styloid process of radius is located in the fossa
and the radial artery passes through to the rst metacarpal
bone space. Cephalic vein is one of the important contents in
the shallow structure of snuff fossa, transecting tendon of
extensor carpi radialis longus from inside to outside and then
up.
Muscular (Tendon) Marks ontheFoot
Tendon of tibialis anterior: From the medial side of the
dorsum of the foot oblique forward and down, and ends at
the medial side of medial cuneiform bone and the rst metatarsal base. It can be touched clearly when the calcaneal joint
is in dorsiexion and inversion position.
Tendon of extensor hallucis longus: It goes forward
from the dorsum of the foot to the dorsum of the hallux. It
can be clearly seen when the hallux is in dorsiexion
position.
Tendon of extensor digitorum longus: When tendon of
extensor digitorum longus reaches the lower part of the cruciate ligament, it is divided into ve tendons, and the four
medial tendons go to the dorsum of the second to the fth
toes respectively. The another one runs to the dorsum of the
fth metatarsal trochanter, called the third peroneal tendon.
These tendons can be clearly seen or touched when the toes
extend.
Tendon of peroneus longus and peroneus brevis:
Tendon of peroneus longus and peroneus brevis go forward and downwards through the posterior side of the lateral malleolus, tendon of peroneus brevis goes forward
and downwards through the upper part of the calcaneal
trochlear process, and tendon of peroneus longus goes forward and downwards through the posterior side of the calcaneal trochlear process. The two tendons can be touched
when the calcaneal joint is in planta extion and eversion
position.
2.1.2 Hand Positions
Resting Position oftheHand
The resting position of the hand is the natural half-clenched
position during sleep or general anesthesia (Fig.2.3). Dorsal
2 Anatomy oftheHand andFoot
Fig. 2.3 Resting position of the hand
Fig. 2.4 Functional position of the hand
exion of the wrist (10° to 15°) with slight ulnar inclination.
The thumb is slightly abducted and the nger pulp touches
the radial edge of the distal interphalangeal joint of the index
nger. Metacarpal phalangeal joint and interphalangeal joint
of the other ngers are in semi-exion position, and the more
to the ulnar side, the greater the exion is. The index nger
tilts slightly to the ulnar side and the little nger tilts slightly
to the radial side. The exor and extensor muscles in this
position have a relative balance that would be disrupted
when a hand is injured.
Functional Position oftheHand
The functional position of the hand is similar to the position
that the hand holding a teacup. It is also the position that the
hand can exert its maximum function (Fig.2.4). Dorsal exion of the wrist (about 30°) with slight ulnar inclination
(about 10°), the thumb is abducted totally, and metacarpophalangeal joint and interphalangeal joint are slightly exed.
The other ngers are separated with different degrees of exion, that is, metacarpal phalangeal joint exion of 30° to 45°,
2.1 Holistic View
11
Fig. 2.5 The pinching position of the hand
proximal interphalangeal joint exion of 60° to 80°, and distal interphalangeal joint exion of 10° to 15°. When in the
functional position, the hand can play its maximum function.
So in the case of a hand fracture, the hand should generally
be xed in the functional position.
The Pinching Position oftheHand
The nger pulp of the thumb and the index nger (sometimes
accompanied by the middle nger) are closely attached, to
hold small objects (such as writing and pinching needles),
called the pinching position (Fig.2.5). In this position, the
wrist is obviously dorsal exed, the rst metacarpal bone
rotates and abducts, metacarpophalangeal and interphalangeal joints of the thumb are slightly exed, the index nger
is exed also, and the tip of thumb and index nger touches
each other like the arms of a pair of pliers.
The Holding Position oftheHand
Holding is an important function of the hand, which can be
divided into two forms: strong and precise. In strong form,
wrist dorsiexion, metacarpal phalangeal joints, and interphalangeal joints all ex at 90° and adduct, enabling the
exor longus of the nger to rmly press the object on the
palm (Fig.2.6). In precise form, wrist dorsiexion or palmar
exion, ngers half fold, the thumb is opposite to the other
ngers. In this position, the interosseous and lumbrical muscles of the hand enable the ngers to make various movements, which could quickly shift from one position to
another. These two forms can also exist together.
Fig. 2.6 The holding position of the hand
2.1.3 Body Surface Reection
Reection ofHand Bones andJoints (Fig.2.7)
1. Pisiform bone: The wrist distal crease just passes through
the proximal end of pisiform bone.
2. Uncus of hamate bone: It is located about 1 cm away
from the radial side of pisiform bone.
3. Scaphoid node: The medial side is covered by the exor
carpi radialis, and the distal side is overlapped by trapezium bone, which is not easy to be reached. It is obvious
when the wrist is dorsal exed.
4. Tubercle of trapezium bone: Next to the distal scaphoid
node.
5. Radiocarpal joint: It is under wrist proximal crease.
Styloid process of radius is about 1.2cm lower than styloid process of ulna.
6. Metacarpophalangeal joints: The metacarpal phalangeal
joint of the index nger is just opposite to a little distal
side of the transverse part of thenar creaseon, the metacarpal phalangeal joints of the middle, ring, and little nger are just opposite to a little distal side of plamar distal
crease, the metacarpal phalangeal joint of the thumb is
just opposite to a little distal side of proximal nger
crease.
7. Interphalangeal joint: Proximal interphalangeal joint is
just opposite to middle nger crease, distal interphalangeal joint is just opposite to a little distal side of distal
nger crease, to the thumb, interphalangeal joint is just
opposite to distal nger crease.
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2 Anatomy oftheHand andFoot
Fig. 2.7 Reection of hand bones and joints
Reection ofVascular andNerves (Figs.2.8, 2.9,
2.10, 2.11, 2.12, 2.13, 2.14 and2.15)
1. Ulnar nerve and ulnar artery: Ulnar nerve passes along
the radial side of the pisiform bone, ulnar artery also
resides on the radial side of the nerve.
2. Supercial palmar arch: An arc is drawn from the
radial side of the pisiform bone and connected to the
midpoint of the midline of the metacarpal line, which
roughly represents the ulnar part of the supercial palmar arch.
3. Deep palmar arch: About 1 cm proximal to supercial
palmar arch.
4. Recurrent branch of median nerve: The one-third of
radial or ulnar part of the proximal thenar crease is the
course of this never that would be involved if this area is
injured.
5. Deep branches of ulnar nerve: Between the distal margin
of the pisiform bone and the proximal margin of hamate
bone, walking along with deep palmar arch.
6. Digital arteries and nerves: Common palmar digital artery
and common palmar digital nerve walk together, nerve
resides deep surface. The artery bifurcated at 1.25 cm
from the edge of nger web to form the proper palmar
digital artery, and the nerve bifurcated a little more proximal than the artery. In the plane of the metacarpophalangeal joint, the proper arteries and nerves were arranged at
the margins of each metacarpophalangeal surface, then
the nerve runs palmar to the artery.
2.1 Holistic View
Limb Arteries
Fig. 2.8 Upper limb arteries
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Fig. 2.9 Upper limb arteries
14
a
Limb Veins
Fig. 2.10 Upper limb veins
2 Anatomy oftheHand andFoot
b
a
Fig. 2.11 Upper limb veins
b
a
a
2.1 Holistic View
Lymphatic Vessels ofLimbs
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b
c
Fig. 2.12 Lymphatic vessels and lymph nodes of upper limb
b
Fig. 2.13 Lymphatic vessels and lymph nodes of lower limb
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Extrinsic Muscles ofHand andFoot
a
2 Anatomy oftheHand andFoot
b
Fig. 2.14 Extrinsic muscles of hand. (a) Extensor digitorum. (b) Flexor digitorum
c
2.1 Holistic View
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a
b
d
Fig. 2.15 Extrinsic muscles of foot
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2 Anatomy oftheHand andFoot
2.2 Applied Anatomy oftheHand
2.2.1 Dorsum ofHand
Supercial Structures
The skin on the dorsum of hand is thinner, with hairs and
sebaceous glands, full of elasticity, and easy to move due to
loose combination with the supercial fascia. The skin will
be tight when making a st, and will not be too relaxed when
straightening ngers, so trauma will easily lead to avulsion.
Dorsal Venous Rete ofHand
Supercial veins in the supercial fascia anastomosed with
each other to form dorsal venous rete of hand (Fig.2.16),
which can be divided into ve types (Fig.2.17). Located on
the supercial side of the cutaneous nerve, which receives
the supercial layers of the ngers and palm and the veins
from deep in the hand. There are many dorsal veins in the
hand with large diameter. Most of the veins in the hand are
collected and returned to the forearm. The radial and ulnar
digital veins are distributed on both sides of the dorsal side of
a
each nger, and they are anastomosed to form the digital
venous arch except collecting the small branches on the
metacarpal surface of the nger.
The radial and ulnar digital veins of the adjacent ngers
converge at the metacarpal phalangeal joint to form the second to fourth dorsal metacarpal vein, and the metacarpal
intercephalic vein enters into it at the conuence. The second
dorsal metacarpal vein receives veins on the ulnar and radial
sides of the index nger, and each dorsal metacarpal vein
moves proximally along the metacarpal space to form a
venous arch or network on the dorsum of hand. To the dorsum
of wrist, the radial and ulnar ends of the arch or net continue
to be the starting parts of cephalic vein and balsilic vein.
The blood ow of hand mainly relies on the dorsal veins of
hand, when in wrist replantation, which must be carefully anastomosed, in order to ensure the survival of the replanted hand.
Supercial Lymph Vessels
The lymphatic reux of dorsum of hand is similar to that of the
vein, which also forms a rich lymphatic network. The supercial lymphatic network at the distal end of the palm ows to
b
Fig. 2.16 Dorsal venous rete of hand. (a) Object specimen. (b) Cast specimen. (1) Dorsal venous rete of hand. (2) Dorsal digital vein. (3) Cephalic
vein. (4) Basilic vein
2.2 Applied Anatomy oftheHand
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Fig. 2.17 The main types of dorsal veins of hand. (I) Ach type: The
dorsal metacarpal vein forms a large venous arch in dors hand. (II) Ach
type: The dorsal metacarpal vein forms a larger venous arch on the dorsal part of the wrist and sometimes forms a secondary or tertiary venous
arch on the dorsum of hand; (III) Net type: The 2nd–4th dorsal metacar-
the lymphatic network at dorsum of hand. Therefore, when the
hand is infected, the dorsum of hand will be more swollen.
Cutaneous Nerves
Branch of cutaneous nerve (Fig. 2.18) (1) Supercial
branch of radial nerve: Distributed on the dorsal radial half
of hand and emitting ve dorsal digital nerves distributed on
the skin of the thumb, index nger, and the opposite edge of
the middle nger; (2) Dorsal branch of ulnar nerve:
Distributed on the dorsal ulnar half of hand and emitting ve
dorsal digital nerves distributed on the skin of the little, ring
nger and the opposite edge of the middle nger; (3) Lateral
antebrachial cutaneous nerve: Distributed on the dorsal
radial side of the wrist; (4) Proper palmar digital nerve
(median nerve): Distributed in the distal dorsal position of
the radial three-and-a-half ngers.
Distribution type of cutaneous nerve (Fig.2.19) Type I:
Supercial branch of radial nerve and dorsal branch of ulnar
nerve are distributed in two and a half ngers on radial and
ulnar side, respectively, accounting for 60.92%. Type II: The
distribution is the same as before, and the two nerves are
connected by anastomotic branches, accounting for 2.46%.
Type III: The distribution of dorsal branch of ulnar nerve is
larger than that of supercial branch of radial nerve, accounting for 3.28%. Type IV: The distribution of supercial branch
of radial nerve is larger than that of dorsal branch of ulnar
nerve, accounting for 28.69%. Type V: Supercial branch of
radial nerve is distributed in whole dorsum of hand, and only
a small dorsal branch of ulnar nerve is left or absent, accounting for 1.92%. Type VI: Lateral antebrachial cutaneous nerve
replaces supercial branch of radial nerve and is distributed
in dorsum of hand. Only a small supercial branch of radial
nerve is left or absent, accounting for 2.73%.
pal vein is large, merges to the proximal side gradually, forms a vein
trunk; (IV) Net type: The 2nd–3rd dorsal metacarpal vein is large, forming a vein trunk; the other veins are small and reticulate; (V) Net type:
The 3rd–4th dorsal metacarpal vein is large, forming a vein trunk; the
other veins are small
Fig. 2.18 Branch of cutaneous nerve. (1) Supercial branch of radial
nerve. (2) Dorsal branch of ulnar nerve. (3) Cephalic vein. (4) Basilic
vein. (5) Dorsal venous rete of hand
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