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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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30
2 Anatomy oftheHand andFoot
a
b
Fig. 2.32 Position, composition, and branches of deep palmar arch.
(a) Object specimen. (b) Cast specimen. (1) Deep palmar arc. (2)
Supercial palmar arc. (3) Supercial palmar branch of radial artery.
(4) Terminal branch of radial artery. (5) Deep palmar branch of ulnar
Nerves
Ulnar nerve, median nerve, and their branches are distributed
on palm of hand (Fig.2.33).
Ulnar nerve: The main trunk passes on the supercial
side of the exor retinaculum, descending between radial
side of pisiform bone and ulnar artery, and then on deep side
of palmaris brevis to palm, which is divided into supercial
and deep branches at laeral and lower part of pisiform bone.
(1) Supercial branch of ulnar nerve: It runs medial to ulnar
artery, gives off a branch to palmaris brevis, and divides into
proper palmar digital nerve and common palmar digital
nerve on deep surface of this muscle. Proper palmar digital
nerve is distributed to ulnar margin of palmar surface of the
little nger. Common palmar digital nerve is divided into
two proper palmar digital nerves at web space which are distributed to the skin at opposite edge of the little nger and the
ring nger (Fig. 2.34). (2) Deep branch of ulnar nerve: It
runs with deep palmar branch of ulnar artery, passes through
the beginning of hypothenar, accompanies by deep palmar
arch, and branches to hypothenar, all interosseous muscles,
lumbricals of the third and fourth nger, and adductor pollicis. The deep branch between pisiform bone and hamate
artery. (6) Terminal branch of ulnar branch. (7) Principal artery of
thumb. (8) Common palmar digital arteries. (9) Proper palmar digital
artery. (10) Ulnar palmar artery of quinary nger
bone is supercial and easy to be injured, which presents as
“clawed hand” after injury due to paralysis of adductor pollicis, interosseous muscles, and abductor digiti minimi.
Median nerve: It enters palm through carpal canal and
goes on deep side of supercial palmar arch (slightly to
radial side) and supercial exor tendon. It usually divides
into two branches immediately after carpal canal. (1) Lateral
branch: This branch is relatively smaller, which rst produces a reverse branch and then divides into three proper palmar digital nerves, which are distributed on both sides of the
thumb and radial palmar skin of the index nger respectively
(Fig. 2.34). Reverse branch arises at the lower margin of
exor retinaculum and runs proximally around medial margin of exor pollicis. The branches supply exor pollicis,
extensor pollicis, and opponens pollicis. The surface projection of median nerve is the midpoint of medial margin of
thenar, which is equivalent to about 2.5 cm below carpal
canal. So incision should not be made here in order to avoid
the loss of thumb function caused by nerve injury. (2) Medial
branch: This branch is relatively larger and immediately
divides into two common palmar digital nerves.
Accompanying the eponymous blood vessels to nger web,
b
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31
a
b
Fig. 2.33 Ulnar nerve, median nerve, and the branches. (a) Median
nerve ulnar nerve and the branches. (b) Course, branches of deep
branch of ulnar nerve. (1) Ulnar nerve. (2) Pisiform bone. (3) Ulnar
artery. (4) Supercial branch of ulnar nerve. (5) Deep branch of ulnar
nerve. (6) Common palmar digital nerve. (7) Proper palmar digital
a
Fig. 2.34 Innervation of hand skin. (a) Anterior view. (b) Dorsal view
nerve. (8) Deep branch of ulnar artery. (9) Deep palmar arc. (10) Lateral
branch. (11) Medial branch. (12) Reverse branch. (13) Abductor digiti
minimi. (14) Flexor digiti minimi brevis. (15) Opponens digiti minimi.
(16) Lumbricals. (17) Adductor pollicis (transverse head). (18)
Adductor pollicis (oblique head). (19) Interosseous muscle
32
2 Anatomy oftheHand andFoot
sending out two proper palmar digital nerves distributed on
the skin of the opposite border of the second to the fourth
nger on the proximal side of the artery branch. Median
nerve also gives off muscle branches to supply the rst and
second lumbricals.
2.2.3 Fingers
Fingers are connected with the palm by metacarpophalangeal
joints, and the movement is very exible. The thumb is thick
and short, with only two phalanx bones, but it has the largest
range of motion and can perform 50% of the hand function.
Supercial Structrues
Skin
The palmar skin of the ngers is thicker, rich in sweat glands
and ngerprints, but without hair and sebaceous glands, so it
is not easy to cause pain and swelling. In nger pulp, nerve
endings are very rich, especially sensitive to touch to distinguish the shape and texture of objects. In the site of nger
and palm crease, because there is no subcutaneous tissue, so
the skin is directly connected with tendinous sheath, and
when the wound is infected, often leads to tenosynovitis.
Dorsal skin of nger is thinner, subcutaneous fat is less, and
activity is bigger than palmar. The blood supply to the skin of
ngers is rich and should be kept as much as possible in case
of trauma or burns.
Nail
A derived structure of dorsal skin consisting of multiple layers of tightly connected keratinized epithelial cells. It can
protect the ngertip and support the function of the nger. It
not only gives the nger beauty but also is vulnerable site to
be injured.
Subcutaneous Tissue
The subcutaneous fat in palm of ngers is thick and accumulates into a ball, with ber bundles in, connecting the
skin to phalangeal periosteum and tendinous sheath
(Fig.2.35). When is infected, it often spreads to the deep
layer. Finger dorsal subcutaneous fat is thin and loose, with
a greater glide.
Finger artery: Theoretically, each nger is supplied by
two palmar and two dorsal digital arteries. Actually, the obvious trunk that can be seen by the naked eye is palmaral digital arteries, doral digital arteries are generally underdeveloped
(except for the thumb) and is only a few scattered small
branches.
Dorsal digital artery: It is variety. The dorsal digital
arteries of the index, middle, and ring ngers are derived
from the corresponding dorsal metacarpal arteries (Fig.2.36).
Dorsal digital artery is mostly distributed to the proximal
half of proximal phalangeal or to dorsal side of the proximal
interphalangeal joint, but rarely to the distal phalangeal. The
radial dorsal digital artery of thumb with an external diameter of about 0.5mm, comes from the branch of the nasal cavity of radial artery. The ulnar dorsal digital artery originates
a
b
c
Fig. 2.35 Structures of nger. (a) Sagittal view (specimen). (b) Schematic diagram. (c) Cross-section of phalangette. (1) Phalangette. (2) Fat
ac
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Fig. 2.36 Origin of dorsal digital arteries. (1) Dorsal digital arteries.
(2) Second metacarpal artery. (3) Anastomotic branch. (4) Proper palmar digital arteries
b
33
from rst dorsal metacarpal artery with an external diameter
of about 0.8mm. The radial dorsal digital artery of little nger originates from fourth dorsal metacarpal artery, while the
ulnar side originates from a branch of dorsal carpal artery,
with an external diameter of 0.3–0.4 mm.
Proper palmar digital arteries: The common palmar
digital artery is divided into two proper palmar digital arteries in the metacarpal head plane. The latter runs distal along
both sides of exor digitorum tendon sheath and travels
with the proper digital nerve in a narrow vascular and nerve
bundle of osseous cutaneous ligament. Proper palmar digital artery is located on lateral and dorsal side of proper palmar digital nerve and its outer diameter is smaller than the
nerve. According to this anatomical relationship, the arteries and nerves can be found successfully in nger replantation. Proper palmar digital artery sends out branches to
Fig. 2.37 The course, branch, and distribution of nger arteries. (a)
Palmar view of middle nger. (b) Lateral view of middle nger. (c)
Dorsal view of middle nger. (1) Proper digital arteries. (2) Dorsal
metacarpal arteries. (3) Dorsal perforator branch. (4) Proper digital
nerve. (5) Anastomotic branch
34
a
2 Anatomy oftheHand andFoot
b
Fig. 2.38 Fingertip vascular network. (a) Palmar view. (b) Dorsal
view. (1) Proper palmar digital artery. (2) Palmar digital arc. (3) Distal
phalanx. (4) Proximal palmar arc. (5) Distal palmar arc. (6) Dorsal
branch of middle phalanx. (7) Proximal dorsal arc. (8) Nail arterial network. (9) Distal dorsal arc
palmar side and anastomosis to corresponding branches on
opposite side to form the digital palmar arch and sends out
several perforating arteries and articular branches to dorsum, distributed in dorsum, and interphalangeal joints of
ngers (Fig.2.37).
In the distal phalanx, the main trunk of proper palmar
digital artery gradually moved to medial side and anastomosed with the contralateral artery, forming ngertip vascular network. At the midpoint between nail bed and distal
interphalangeal joint, a transverse anastomotic branch with a
diameter of about 0.5 mm is produced at a constant rate,
which anastomosis coincides with the contralateral homonymous branch to form distal dorsal digital arch (Fig. 2.38),
that gives off ve main branches distal on supercial of
exor digitorum. One on each side, with an outer diameter of
0.1–0.2mm. There are three in the middle, representing the
terminal branch of nger pulp, and the outer diameter is 0.2–
0.3mm. The ve main trunks intersect each other, and any of
them can be anastomosed.
There are ulnar and radial proper palmar digital arteries
on the palm of thumb. The former is thicker with an initial
outer diameter of 1.8mm, which is mainly separated from
the main artery of thumb, which is then released through the
ulnar side of exor pollicis longus, across between adductor
pollicis insertion and the ulnar sesamoid bone to distal
thumb. The latter is thinner, with an initial outer diameter of
1.1mm, and originates from the main artery of thumb (85%)
and supercial palmar branch of radial artery (15%), which
arises after passing through deep surface of exor pollicis
Fig. 2.39 The course,
branches, and distribution of
thumb artery. (a) Palmar view
of thumb. (b) Dorsal view of
thumb. (1) Radial proper
palmar artery of thumb. (2)
Ulnar proper palmar artery of
thumb. (3) Dorsal artery of
thumb. (4) Radial dorsal
cutaneous nerve of thumb. (5)
Abductor pollicis longus. (6)
Extensor pollicis longus. (7)
Extensor pollicis brevis. (8)
Abductor pollicis longus. (9)
Dorsal perforator
a
b
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35
Fig. 2.40 Digital veins.
(a) Cast specimen. (b) Object
specimen
a
b
longus to the radial side, bypass the deep head free margin of
exor pollicis brevis, across between adductor pollicis longus and the radial sesamoid bone to distal thumb. The ulnar
and radial proper palmar digital arteries give off branches in
the distal direction of thumb palm, the lateral skin, soft tissue, etc. Meanwhile, the two arteries communicate with each
other by means of a constant digital, metacarpal arch and
pulp arc (Fig.2.39).
Digital veins The veins of ngers are divided into supercial and deep. Supercial palmar digital veins are close to
skin, which is thin and arises from the ventral network of
ngers. Three or four larger veins are anastomosed to the
proximal side and anastomosed to network along the way,
and branches by both sides to the dorsal, the adjacent supercial veins at web merge into venules and merge into dorsal
digital veins (Fig.2.40).
Supercial dorsal digital vein is the main route of venous
blood reux, which has a certain pattern of movement
between the subcutaneous and extensor digitorum. On both
sides of the ngernail, one to two venules were synthesized
from methyl to distal phalanx dorsal venules, with an external diameter of 0.5–0.6mm and a net conuence towards the
proximal end. These converging venules form several veins
with an external diameter of 0.8–1.0mm on the dorsal side
of the proximal interphalangeal joint, which tend to be concentrated in the dorsal part of the proximal phalangeal nger
and form a network, and then form one to three layers of
venous arch (Fig.2.41). At the base of ngers, the venous arc
adjacent to each other converge to form dorsal metacarpal
vein or intercephalic vein. The distribution of supercial dorsal digital vein is as follows: (1) Focus on the clock face at
10–2o’clock. (2) Off-center phenomenon: Taking the middle line of middle nger as the center line, the supercial
dorsal vein of thumb and index nger is more to the radial
side, and the diameter is also thick; the supercial dorsal
vein of ring and little nger is more to the ulnar side. The
phenomenon is most obvious in index and little nger.
Deep digital vein is generally accompanied by proper palmar digital artery and dorsal digital artery, but diameter of
the vein accompanied is smaller and the position is not constant. There are valves in digital veins. Dorsal veins of hand
have a pair of venous valves spaced about 2cm apart. The
valve is opened from the distal end to the proximal end and
from the palmar side to the dorsal end to ensure that venous
36
2 Anatomy oftheHand andFoot
Fig. 2.41 The distribution type of supercial digital vein. (a) The dis-
tribution type of supercial digital vein in the dorsal digital aspect. (b)
The distribution type of supercial digital vein in the distal volar digital
blood ows from the distal end to the proximal end and from
the palmar side to the dorsal end.
Flexor Digitorum
Morphological Structure Characteristics ofFlexor
Digitorum
Flexor digitorum include supercialis and profundus. Thumb
has only one exor tendon, and the other ngers have super-
aspect. (c) The distribution type of supercial digital vein in the distal
lateral digital aspect. (d) The distribution of supercial digital vein in
the lateral digital aspect
cial exor tendon and deep exor tendon, which run in the
tendinous sheath of each nger. At the proximal phalanx,
exor digitorum supercialis is located on the palmar side of
exor digitorum profundus, runs around exor digitorum
profundus, and then divides into two distal segments,
attached to both sides of middle phalanx, between which a
tendon hiatus is formed, allowing exor digitorum profundus to pass through (Fig.2.42a). Flexor digitorum profundus
comes out of the hole of the tendon and ends at the bottom of
2.2 Applied Anatomy oftheHand
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37
a
b
Fig. 2.42 The shape of exor digitorum of ngertip. (a) Object speci-
men. (b) Schematic diagram. (1) Flexor digitorum supercialis. (2)
Flexor digitorum profundus. (3) Interossei. (4) Lumbricals. (5) Vincula
the phalanx. Flexor digitorum supercialis mainly bends
proximal interphalangeal joint, metacarpophalangeal joint
and carpal joint, and exor digitorum profundus bends distal
interphalangeal joint, also makes nger and wrist completely
exor.
tendinum. (6) Mesotendon. (7) Extensor digitorum. (8) Aponeurosis
dorsalis digiti
Vincula tendinum is synovial plica located in the sheath
of exor digitorum, which can be divided into short vincula
tendinum and long vincula tendinum according to their morphology. Each exor digitorum has two types of vincula
tendinum (Fig. 2.42b).Short vincula tendinum: There are
38
2 Anatomy oftheHand andFoot
a
b
c
Fig. 2.43 Flexor digitorum and tendinous sheath. (a) Object specimen.
(b) Schematic diagram. (c) Cross section. (1) Synovial sheath of exor
digitorum. (2) Fibrous sheath. (3) Visceral layer of synovial sheath. (4)
two triangles, located at the proximal end of supercial and
deep exor tendon, with the proximal edge free, the dorsal
side attached to the midsagittal position palmar side of phalangeals, and the palmar side attached to the dorsal side of
tendons. The blood supply comes from the branches of the
palmar arterial arch and the small periosteum vessels at the
stopping point, and the vessels anastomose with each other
to form a vascular network.
Long vincula tendinum: It is a long thin cable structure,
and its shape, position, and number are not as constant as the
short ones. Long vincula tendinum of exor digitorum profundus is mostly directly or indirectly from short vincula
tendinum of exor digitorum supercialis which is issued
near the insertion point and penetrates the center of exor
digitorum supercialis to exor digitorum profundus.
Sheath Digitorum
Sheath digitorum is the sheath tube surrounding exor digitorum supercialis or exor digitorum profundus, which is
composed of synovial sheath and brous sheath of tendons
(Fig.2.43).
Parietal layer of synovial sheath. (5) Mesotendon. (6) Phalanges. (7)
Proper palmar digital vasculars and nerves
Partition of exor digitorum: Clinically, the therapeutic
principles and functional prognosis of tendon injuries in different parts are also very different. Therefore, it is of clinical
signicance to divide the exor digitorum by its location. The
exor digitorum is usually divided into ve regions (Fig.2.44).
End of tendon (I or TI region): This region is from distal
phalanx tendon to the middle of middle phalanx (the thumb is
the middle of proximal phalanx), and proximal phalanx length
is about 1.5cm. There is only one exor digitorum profundus
or exor pollicis, which is partially enclosed in tendinous
sheath. There is a constant short vincula tendinum at the proximal phalanx and a good blood supply. The movement of tendon is small, and the early repair effect will be better.
Sheath region (II region or T II region): Also known as
“no man’s land.” This region is from the middle of middle
phalanx to distal palmar crease. There are two exor tendons
in this region which are located in exor tendinous sheath,
and the blood supply is poor. Therefore, the surgical treatment of tendon injury in this region is difcult and ineffective. The thumb “T II region”, although only one exor
pollicis, is relatively simple, but on both sides of metacarpo-
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39
Fig. 2.44 Partition of exor digitorum
phalangeal joint from two pieces of sesamoid clamping,
from the narrow channel, in pathological situation, adhesion
cannot be avoided.
Palm region (III region or T III region): This region
extends from distal palmar crease to distal margin of exor
retinaculum. In this segment, the exor tendons of thumb
and little nger are encapsulated by separate radial and ulnar
synovial sacs. The exor tendon of the middle three ngers
is located in the space of loose connective tissue, surrounded
by parathyroid tissue, with lumbrical muscle rising from
exor digitorum profundus.
Carpal region (IV region): Located in a carpal tunnel
which is a narrow passage. The nine exor tendons in this
region are crowded with median nerve, which is the site of
nerve entrapment syndrome.
Forearm region (V region): This region is above exor
retinaculum. In this region, there are more loose connective
tissues, easy-to-perform tendon repair, and less postoperative adhesion, which has little inuence on the sliding function of tendons.
Fig. 2.45 The morphology of aponeurosis dorsalis digiti
Extensor Digitorum
Morphological Structure Characteristics ofExtensor
Digitorum
Extensor digitorum crosses the metacarpal head and the dorsum of proximal phalanx and expands to form aponeurosis
dosalis digiti, also known as the tendon hood (Fig. 2.45).
Aponeurosis dosalis digiti is divided into three longitudinal
bands to the far side, and the middle band is forward. Some
bers from the two bands are added, ending at the base of
middle phalanx and joint capsule. On either side of proximal
phalanx two lateral bands are added from interosseous and
lumbrical tendons running from the palm to the dorsum. The
two lateral bands merge in the dorsal part of middle phalanx
and then end at the dorsal part of distal phalanx and joint
capsule. The main function of aponeurosis dosalis digiti is to
stabilize the metacarpophalangeal joint and the interphalangeal joint and to provide the structural basis for internal muscles of hand. If extensor digitorum is ruptured and the joints
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