1

1. THE MUSCLES OF THE SHOULDER GIRDLE AND ARM. THE ARMPIT

2. THE MUSCLES OF THE FOREARM AND HAND

3. THE TOPOGRAPHY OF THE UPPER EXTREMITY, FASCIAE, SYNOVIAL BURSAE AND SHEATHS OF THE UPPER EXTREMITY

LESSON 10

Theme 1. THE MUSCLES OF THE SHOULDER GIRDLE AND ARM. THE ARMPIT

: : backanatomy-blog-reardeltoid

Musculature of upper limb divides into muscles of the shoulder girdle and free limb.

Shoulder Girdle Musculature

Deltoid

Origin:

1. lateral, anterior 1/3 of distal clavicle

2. lateral boarder of the acromion

3. scapular spine

Insertion: deltoid tuberosity of humerus

Action:

1. abducts arm

2. flexion and medial rotation (anterior portion)

3. extension and lateral rotation (posterior portion)

Blood:

1. posterior humeral circumflex artery

2. deltoid branch of thoracoacromial artery

Nerve: axillary nerve, C5,6

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Supraspinatus

Origin:

1. supraspinous fossa

2. muscle fascia

Insertion: uppermost of three facets of the greater tubercle of humerus

Action:

1. abduction of arm (first 15-20)

2. stabilizes glenohumeral joint

Blood: suprascapular artery (poorly supplied)

Nerve: suprascapular nerve, C5,6

: : shoulder

Infraspinatus

Origin:

1. infraspinous fossa

2. muscle fascia

Insertion: middle facet of greater tubercle of humerus

Action:

1. external rotation of the humerus

2. stabilizes the glenohumeral joint

Blood:

1. suprascapular artery

2. scapular circumflex artery

Nerve: suprascapular nerve, C5,6

: : shoulder-muscles

Teres minor

Origin: middle half of the scapulas lateral margin

Insertion: lowest of three facets of the greater tubercle of humerus

Action:

1. lateral rotation of the humerus

2. stabilizes the glenohumeral joint

Blood: scapular circumflex artery

Nerve: axillary nerve, C5,6

Teres major

Origin: inferior, lateral margin of the scapula

Insertion: crest of lesser tubercle (just medial to the insertion of latissimus dorsi)

Action:

1. assists in adduction of arm

2. assists in medial rotation of arm

3. assists in extension from an flexed position

Blood: thoracodorsal artery

Nerve: lower subscapular nerve, C5,6

: : 13

Subscapularis

Origin: subscapular fossa

Insertion: lesser tubercle of humerus

Action:

1. medial rotation of the humerus

2. stabilizes the glenohumeral joint

Blood: Branches of subscapular artery

Nerve: upper & lower subscapular nerves, C5,6

: : rotator-cuff-muscles

Brachium (arm) Musculature

ANTERIOR GROUP

: : arm_front

Coracobrachialis

Origin: coracoid process of the scapula Insertion: medial shaft of the humerus at about its middle Action:

1.flexes the humerus 2.assists to adduct the humerus

Blood: muscular branches of the brachial artery Nerve: musculocutaneous nerve, C5,6,(C7)

Biceps brachii

Origin:

1.long head- supraglenoid tubercle and glenohumeral labrum 2.short head- tip of the coracoid process of the scapula

Insertion:

1.radial tuberosity 2.bicipital aponeurosis

Action:

1.flexes the forearm at the elbow (when supinated) 2.supinates forearm from neutral 3.stabilizes anterior aspect of shoulder 4.flexes shoulder (weak if at all)

Blood: muscular branches of brachial artery Nerve: musculocutaneous nerve, C5,6

: : 113037-004-D4CF5BB4

Brachialis

Origin:

1.lower 1/2 of anterior humerus 2.both intermuscular septa

Insertion:

1.ulnar tuberosity 2.coronoid process of ulna slightly

Action: elbow flexion (major mover) Blood:

1.muscular branches of brachial artery 2.radial recurrent artery

Nerve: musculocutaneous nerve, C5,6

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POSTERIOR GROUP

Triceps brachii

Origin:

1.long head - infraglenoid tubercle of the scapula 2.lateral head - upper half of the posterior surface of the shaft of the humerus, and the upper part of the lateral intermuscular septum 3.medial head - posterior shaft of humerus, distal to radial groove and both the medial and lateral intermuscular septum (deep to the long & lateral heads)

Insertion:

1.posterior surface of the olecranon process of the ulna 2.deep fascia of the antebrachium

Action:

1.long - adducts the arm, extends at the shoulder, and a little elbow flexion 2.lateral - extends the forearm at the elbow 3.medial - extends the forearm at the elbow

Blood:

1.muscular branches of the brachial artery 2.superior ulnar collateral artery 3.profunda brachii artery

Nerve: radial nerve, C6,7

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Cross-section through the middle of upper arm. (Eycleshymer and Schoemaker.)

Anconeus

Origin: posterior surface of the lateral epicondyle of the humerus Insertion: lateral aspect of olecranon extending to the lateral part of ulnar body Action:

1.extends the forearm at the elbow 2.supports the elbow when in full extension

Blood: middle collateral artery from the profunda brachii artery Nerve: radial nerve, C7,8

: : muscles

Theme 2. THE MUSCLES OF THE FOREARM AND HAND.

The antibrachial or forearm muscles may be divided into a volar and a dorsal group.

 

The Volar Antibrachial MusclesThese muscles are divided for convenience of description into two groups, superficial and deep.

 

The Superficial Group

Pronator teres.

Palmaris longus.

Flexor carpi radialis.

Flexor carpi ulnaris.

Flexor digitorum sublimis.

  The muscles of this group take origin from the medial epicondyle of the humerus by a common tendon; they receive additional fibers from the deep fascia of the forearm near the elbow, and from the septa which pass from this fascia between the individual muscles.

  The Pronator teres has two heads of originhumeral and ulnar. The humeral head, the larger and more superficial, arises immediately above the medial epicondyle, and from the tendon common to the origin of the other muscles; also from the intermuscular septum between it and the Flexor carpi radialis and from the antibrachial fascia. The ulnar head is a thin fasciculus, which arises from the medial side of the coronoid process of the ulna, and joins the preceding at an acute angle. The median nerve enters the forearm between the two heads of the muscle, and is separated from the ulnar artery by the ulnar head. The muscle passes obliquely across the forearm, and ends in a flat tendon, which is inserted into a rough impression at the middle of the lateral surface of the body of the radius. The lateral border of the muscle forms the medial boundary of a triangular hollow situated in front of the elbow-joint and containing the brachial artery, median nerve, and tendon of the Biceps brachii.

 Variations.Absence of ulnar head; additional slips from the medial intermuscular septum, from the Biceps and from the Brachialis anticus occasionally occur.

  The Flexor carpi radialis lies on the medial side of the preceding muscle. It arises from the medial epicondyle by the common tendon; from the fascia of the forearm; and from the intermuscular septa between it and the Pronator teres laterally, the Palmaris longus medially, and the Flexor digitorum sublimis beneath. Slender and aponeurotic in structure at its commencement, it increases in size, and ends in a tendon which forms rather more than the lower half of its length. This tendon passes through a canal in the lateral part of the transverse carpal ligament and runs through a groove on the greater multangular bone; the groove is converted into a canal by fibrous tissue, and lined by a mucous sheath. The tendon is inserted into the base of the second metacarpal bone, and sends a slip to the base of the third metacarpal bone. The radial artery, in the lower part of the forearm, lies between the tendon of this muscle and the Brachioradialis.

 

Variations.Slips from the tendon of the Biceps, the lacertus fibrosus, the coronoid, and the radius have been found. Its insertion often varies and may be mostly into the annular ligament, the trapezium, or the fourth metacarpal as well as the second or third. The muscle may be absent.

  The Palmaris longus is a slender, fusiform muscle, lying on the medial side of the preceding. It arises from the medial epicondyle of the humerus by the common tendon, from the intermuscular septa between it and the adjacent muscles, and from the antibrachial fascia. It ends in a slender, flattened tendon, which passes over the upper part of the transverse carpal ligament, and is inserted into the central part of the transverse carpal ligament and lower part of the palmar aponeurosis, frequently sending a tendinous slip to the short muscles of the thumb.

 

Variations.One of the most variable muscles in the body. This muscle is often absent about (10 per cent.), and is subject to many variations; it may be tendinous above and muscular below; or it may be muscular in the center with a tendon above and below; or it may present two muscular bundles with a central tendon; or finally it may consist solely of a tendinous band. The muscle may be double. Slips of origin from the coronoid process or from the radius have been seen.Partial or complete insertion into the fascia of the forearm, into the tendon of the Flexor carpi ulnaris and pisiform bone, into the navicular, and into the muscles of the little finger have been observed.

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Front of the left forearm. Superficial muscles. : : C:\Documents and Settings\xata\ \\\gray\henry gray anatomy\www.bartleby.com\107\Images\large\image415.gif

Front of the left forearm. Deep muscles.

 

  The Flexor carpi ulnaris lies along the ulnar side of the forearm. It arises by two heads, humeral and ulnar, connected by a tendinous arch, beneath which the ulnar nerve and posterior ulnar recurrent artery pass. The humeral head arises from the medial epicondyle of the humerus by the common tendon; the ulnar head arises from the medial margin of the olecranon and from the upper two-thirds of the dorsal border of the ulna by an aponeurosis, common to it and the Extensor carpi ulnaris and Flexor digitorum profundus; and from the intermuscular septum between it and the Flexor digitorum sublimis. The fibers end in a tendon, which occupies the anterior part of the lower half of the muscle and is inserted into the pisiform bone, and is prolonged from this to the hamate and fifth metacarpal bones by the pisohamate and pisometacarpal ligaments; it is also attached by a few fibers to the transverse carpal ligament. The ulnar vessels and nerve lie on the lateral side of the tendon of this muscle, in the lower two-thirds of the forearm.

 

Variations.Slips of origin from the coronoid. The Epitrochleo-anconæus, a small muscle often present runs from the back of the inner condyle to the olecranon, over the ulnar nerve.

  The Flexor digitorum is placed beneath the previous muscle; it is the largest of the muscles of the superficial group, and arises by three headshumeral, ulnar, and radial. The humeral head arises from the medial epicondyle of the humerus by the common tendon, from the ulnar collateral ligament of the elbow-joint, and from the intermuscular septa between it and the preceding muscles. The ulnar head arises from the medial side of the coronoid process, above the ulnar origin of the Pronator teres. The radial head arises from the oblique line of the radius, extending from the radial tuberosity to the insertion of the Pronator teres. The muscle speedily separates into two planes of muscular fibers, superficial and deep: the superficial plane divides into two parts which end in tendons for the middle and ring fingers; the deep plane gives off a muscular slip to join the portion of the superficial plane which is associated with the tendon of the ring finger, and then divides into two parts, which end in tendons for the index and little fingers. As the four tendons thus formed pass beneath the transverse carpal ligament into the palm of the hand, they are arranged in pairs, the superficial pair going to the middle and ring fingers, the deep pair to the index and little fingers. The tendons diverge from one another in the palm and form dorsal relations to the superficial volar arch and digital branches of the median and ulnar nerves. Opposite the bases of the first phalanges each tendon divides into two slips to allow of the passage of the corresponding tendon of the Flexor digitorum profundus; the two slips then reunite and form a grooved channel for the reception of the accompanying tendon of the Flexor digitorum profundus. Finally the tendon divides and is inserted into the sides of the second phalanx about its middle.

 Variations.Absence of radial head, of little finger portion; accessory slips from ulnar tuberosity to the index and middle finger portions; from the inner head to the Flexor profundus; from the ulnar or annular ligament to the little finger.

 

The Deep Group

Flexor digitorum profundus.

Flexor pollicis longus.

Pronator quadratus.

  The Flexor digitorum profundus is situated on the ulnar side of the forearm, immediately beneath the superficial Flexors. It arises from the upper three-fourths of the volar and medial surfaces of the body of the ulna, embracing the insertion of the Brachialis above, and extending below to within a short distance of the Pronator quadratus. It also arises from a depression on the medial side of the coronoid process; by an aponeurosis from the upper three-fourths of the dorsal border of the ulna, in common with the Flexor and Extensor carpi ulnaris; and from the ulnar half of the interosseous membrane. The muscle ends in four tendons which run under the transverse carpal ligament dorsal to the tendons of the Flexor digitorum sublimis. Opposite the first phalanges the tendons pass through the openings in the tendons of the Flexor digitorum sublimis, and are finally inserted into the bases of the last phalanges. The portion of the muscle for the index finger is usually distinct throughout, but the tendons for the middle, ring, and little fingers are connected together by areolar tissue and tendinous slips, as far as the palm of the hand.

 

Variations.The index finger portion may arise partly from the upper part of the radius. Slips from the inner head of the Flexor sublimis, medial epicondyle, or the coronoid are found. Connection with the Flexor pollicis longus.

  Four small muscles, the Lumbricales, are connected with the tendons of the Flexor profundus in the palm. They will be described with the muscles of the hand.

  The Flexor pollicis longus is situated on the radial side of the forearm, lying in the same plane as the preceding. It arises from the grooved volar surface of the body of the radius, extending from immediately below the tuberosity and oblique line to within a short distance of the Pronator quadratus. It arises also from the adjacent part of the interosseous membrane, and generally by a fleshy slip from the medial border of the coronoid process, or from the medial epicondyle of the humerus. The fibers end in a flattened tendon, which passes beneath the transverse carpal ligament, is then lodged between the lateral head of the Flexor pollicis brevis and the oblique part of the Adductor pollicis, and, entering an osseoaponeurotic canal similar to those for the Flexor tendons of the fingers, is inserted into the base of the distal phalanx of the thumb. The volar interosseous nerve and vessels pass downward on the front of the interosseous membrane between the Flexor pollicis longus and Flexor digitorum profundus.

 

Variations.Slips may connect with Flexor sublimis, or Profundus, or Pronator teres. An additional tendon to the index finger is sometimes found.

  The Pronator quadratus is a small, flat, quadrilateral muscle, extending across the front of the lower parts of the radius and ulna. It arises from the pronator ridge on the lower part of the volar surface of the body of the ulna; from the medial part of the volar surface of the lower fourth of the ulna; and from a strong aponeurosis which covers the medial third of the muscle. The fibers pass lateralward and slightly downward, to be inserted into the lower fourth of the lateral border and the volar surface of the body of the radius. The deeper fibers of the muscle are inserted into the triangular area above the ulnar notch of the radiusan attachment comparable with the origin of the Supinator from the triangular area below the radial notch of the ulna.

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Tendons of forefinger and vincula tendina.

Variations.Rarely absent; split into two or three layers; increased attachment upward or downward.

Nerves.All the muscles of the superficial layer are supplied by the median nerve, excepting the Flexor carpi ulnaris, which is supplied by the ulnar. The Pronator teres, the Flexor carpi radialis, and the Palmaris longus derive their supply primarily from the sixth cervical nerve; the Flexor digitorum sublimis from the seventh and eighth cervical and first thoracic nerves, and the Flexor carpi ulnaris from the eighth cervical and first thoracic. Of the deep layer, the Flexor digitorum profundus is supplied by the eighth cervical and first thoracic through the ulnar, and the volar interosseous branch of the median. The Flexor pollicis longus and Pronator quadratus are supplied by the eighth cervical and first thoracic through the volar interosseous branch of the median.

 

Actions.These muscles act upon the forearm, the wrist, and hand. The Pronator teres rotates the radius upon the ulna, rendering the hand prone; when the radius is fixed, it assists in flexing the forearm. The Flexor carpi radialis is a flexor and abductor of the wrist; it also assists in pronating the hand, and in bending the elbow. The Flexor carpi ulnaris is a flexor and adductor of the wrist; it also assists in bending the elbow. The Palmaris longus is a flexor of the wrist-joint; it also assists in flexing the elbow. The Flexor digitorum sublimis flexes first the middle and then the proximal phalanges; it also assists in flexing the wrist and elbow. The Flexor digitorum profundus is one of the flexors of the phalanges. After the Flexor sublimis has bent the second phalanx, the Flexor profundus flexes the terminal one; but it cannot do so until after the contraction of the superficial muscle. It also assists in flexing the wrist. The Flexor pollicis longus is a flexor of the phalanges of the thumb; when the thumb is fixed, it assists in flexing the wrist. The Pronator quadratus rotates the radius upon the ulna, rendering the hand prone.

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Cross-section through the middle of the forearm.

 

 

2. The Dorsal Antibrachial MusclesThese muscles are divided for convenience of description into two groups, superficial and deep.

 

The Superficial Group

Brachioradialis.

Extensor digitorum communis.

Extensor carpi radialis longus.

Extensor digiti quinti proprius.

Extensor carpi radialis brevis.

Extensor carpi ulnaris.

Anconæus.

  The Brachioradialis (Supinator longus) is the most superficial muscle on the radial side of the forearm. It arises from the upper two-thirds of the lateral supracondylar ridge of the humerus, and from the lateral intermuscular septum, being limited above by the groove for the radial nerve. Interposed between it and the Brachialis are the radial nerve and the anastomosis between the anterior branch of the profunda artery and the radial recurrent. The fibers end above the middle of the forearm in a flat tendon, which is inserted into the lateral side of the base of the styloid process of the radius. The tendon is crossed near its insertion by the tendons of the Abductor pollicis longus and Extensor pollicis brevis; on its ulnar side is the radial artery.

 

Variations.Fusion with the Brachialis; tendon of insertion may be divided into two or three slips; insertion partial or complete into the middle of the radius, fasciculi to the tendon of the Biceps, the tuberosity or oblique line of the radius; slips to the Extensor carpi radialis longus or Abductor pollicis longus; absence; rarely doubled.

  The Extensor carpi radialis longus (Extensor carpi radialis longior) is placed partly beneath the Brachioradialis. It arises from the lower third of the lateral supracondylar ridge of the humerus, from the lateral intermuscular septum, and by a few fibers from the common tendon of origin of the Extensor muscles of the forearm. The fibers end at the upper third of the forearm in a flat tendon, which runs along the lateral border of the radius, beneath the Abductor pollicis longus and Extensor pollicis brevis; it then passes beneath the dorsal carpal ligament, where it lies in a groove on the back of the radius common to it and the Extensor carpi radialis brevis, immediately behind the styloid process. It is inserted into the dorsal surface of the base of the second metacarpal bone, on its radial side.

  The Extensor carpi radialis brevis (Extensor carpi radialis brevior) is shorter and thicker than the preceding muscle, beneath which it is placed. It arises from the lateral epicondyle of the humerus, by a tendon common to it and the three following muscles; from the radial collateral ligament of the elbow-joint; from a strong aponeurosis which covers its surface; and from the intermuscular septa between it and the adjacent muscles. The fibers end about the middle of the forearm in a flat tendon, which is closely connected with that of the preceding muscle, and accompanies it to the wrist; it passes beneath the Abductor pollicis longus and Extensor pollicis brevis, then beneath the dorsal carpal ligament, and is inserted into the dorsal surface of the base of the third metacarpal bone on its radial side. Under the dorsal carpal ligament the tendon lies on the back of the radius in a shallow groove, to the ulnar side of that which lodges the tendon of the Extensor carpi radialis, longus, and separated from it by a faint ridge.

  The tendons of the two preceding muscles pass through the same compartment of the dorsal carpal ligament in a single mucous sheath.

 

Variations.Either muscle may split into two or three tendons of insertion to the second and third or even the fourth metacarpal. The two muscles may unite into a single belly with two tendons. Cross slips between the two muscles may occur. The Extensor carpi radialis intermedius rarely arises as a distinct muscle from the humerus, but is not uncommon as an accessory slip from one or both muscles to the second or third or both metacarpals. The Extensor carpi radialis accessorius is occasionally found arising from the humerus with or below the Extensor carpi radialis longus and inserted into the first metacarpal, the Abductor pollicis brevis, the First dorsal interosseous, or elsewhere.

  The Extensor digitorum communis arises from the lateral epicondyle of the humerus, by the common tendon; from the intermuscular septa between it and the adjacent muscles, and from the antibrachial fascia. It divides below into four tendons, which pass, together with that of the Extensor indicis proprius, through a separate compartment of the dorsal carpal ligament, within a mucous sheath. The tendons then diverge on the back of the hand, and are inserted into the second and third phalanges of the fingers in the following manner. Opposite the metacarpophalangeal articulation each tendon is bound by fasciculi to the collateral ligaments and serves as the dorsal ligament of this joint; after having crossed the joint, it spreads out into a broad aponeurosis, which covers the dorsal surface of the first phalanx and is reinforced, in this situation, by the tendons of the Interossei and Lumbricalis. Opposite the first interphalangeal joint this aponeurosis divides into three slips; an intermediate and two collateral: the former is inserted into the base of the second phalanx; and the two collateral, which are continued onward along the sides of the second phalanx, unite by their contiguous margins, and are inserted into the dorsal surface of the last phalanx. As the tendons cross the interphalangeal joints, they furnish them with dorsal ligaments. The tendon to the index finger is accompanied by the Extensor indicis proprius, which lies on its ulnar side. On the back of the hand, the tendons to the middle, ring, and little fingers are connected by two obliquely placed bands, one from the third tendon passing downward and lateralward to the second tendon, and the other passing from the same tendon downward and medialward to the fourth. Occasionally the first tendon is connected to the second by a thin transverse band.

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Posterior surface of the forearm. Superficial muscles.: : C:\Documents and Settings\xata\ \\\gray\henry gray anatomy\www.bartleby.com\107\Images\large\image419.gif

Posterior surface of the forearm. Deep muscles.

 

 

Variations.An increase or decrease in the number of tendons is common; an additional slip to the thumb is sometimes present.

  The Extensor digiti quinti proprius (Extensor minimi digiti) is a slender muscle placed on the medial side of the Extensor digitorum communis, with which it is generally connected. It arises from the common Extensor tendon by a thin tendinous slip, from the intermuscular septa between it and the adjacent muscles. Its tendon runs through a compartment of the dorsal carpal ligament behind the distal radio-ulnar joint, then divides into two as it crosses the hand, and finally joins the expansion of the Extensor digitorum communis tendon on the dorsum of the first phalanx of the little finger.

 

Variations.An additional fibrous slip from the lateral epicondyle; the tendon of insertion may not divide or may send a slip to the ring finger. Absence of muscle rare; fusion of the belly with the Extensor digitorum communis not uncommon.

  The Extensor carpi ulnaris lies on the ulnar side of the forearm. It arises from the lateral epicondyle of the humerus, by the common tendon; by an aponeurosis from the dorsal border of the ulna in common with the Flexor carpi ulnaris and the Flexor digitorum profundus; and from the deep fascia of the forearm. It ends in a tendon, which runs in a groove between the head and the styloid process of the ulna, passing through a separate compartment of the dorsal carpal ligament, and is inserted into the prominent tubercle on the ulnar side of the base of the fifth metacarpal bone.

 

Variations.Doubling; reduction to tendinous band; insertion partially into fourth metacarpal. In many cases (52 per cent.) a slip is continued from the insertion of the tendon anteriorly over the Opponens digiti quinti, to the fascia covering that muscle, the metacarpal bone, the capsule of the metacarpophalangeal articulation, or the first phalanx of the little finger. This slip may be replaced by a muscular fasciculus arising from or near the pisiform.

  The Anconæus is a small triangular muscle which is placed on the back of the elbow-joint, and appears to be a continuation of the Triceps brachii. It arises by a separate tendon from the back part of the lateral epicondyle of the humerus; its fibers diverge and are inserted into the side of the olecranon, and upper fourth of the dorsal surface of the body of the ulna.

 

The Deep Group

Supinator.

Extensor pollicis brevis.

Abductor pollicis longus.

Extensor pollicis longus.

Extensor indicis proprius.

  The Supinator (Supinator brevis) is a broad muscle, curved around the upper third of the radius. It consists of two planes of fibers, between which the deep branch of the radial nerve lies. The two planes arise in commonthe superficial one by tendinous and the deeper by muscular fibersfrom the lateral epicondyle of the humerus; from the radial collateral ligament of the elbow-joint, and the annular ligament; from the ridge on the ulna, which runs obliquely downward from the dorsal end of the radial notch; from the triangular depression below the notch; and from a tendinous expansion which covers the surface of the muscle. The superficial fibers surround the upper part of the radius, and are inserted into the lateral edge of the radial tuberosity and the oblique line of the radius, as low down as the insertion of the Pronator teres. The upper fibers of the deeper plane form a sling-like fasciculus, which encircles the neck of the radius above the tuberosity and is attached to the back part of its medial surface; the greater part of this portion of the muscle is inserted into the dorsal and lateral surfaces of the body of the radius, midway between the oblique line and the head of the bone.

  The Abductor pollicis longus (Extensor oss. metacarpi pollicis) lies immediately below the Supinator and is sometimes united with it. It arises from the lateral part of the dorsal surface of the body of the ulna below the insertion of the Anconæus, from the interosseous membrane, and from the middle third of the dorsal surface of the body of the radius. Passing obliquely downward and lateralward, it ends in a tendon, which runs through a groove on the lateral side of the lower end of the radius, accompanied by the tendon of the Extensor pollicis brevis, and is inserted into the radial side of the base of the first metacarpal bone. It occasionally gives off two slips near its insertion: one to the greater multangular bone and the other to blend with the origin of the Abductor pollicis brevis.

 

Variations.More or less doubling of muscle and tendon with insertion of the extra tendon into the first metacarpal, the greater multangular, or into the Abductor pollicis brevis or Opponens pollicis.

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The Supinator.

 

  The Extensor pollicis brevis (Extensor primi internodii pollicis) lies on the medial side of, and is closely connected with, the Abductor pollicis longus. It arises from the dorsal surface of the body of the radius below that muscle, and from the interosseous membrane. Its direction is similar to that of the Abductor pollicis longus, its tendon passing the same groove on the lateral side of the lower end of the radius, to be inserted into the base of the first phalanx of the thumb.

 

Variations.Absence; fusion of tendon with that of the Extensor pollicis longus.

  The Extensor pollicis longus (Extensor secundi internodii pollicis) is much larger than the preceding muscle, the origin of which it partly covers. It arises from the lateral part of the middle third of the dorsal surface of the body of the ulna below the origin of the Abductor pollicis longus, and from the interosseous membrane. It ends in a tendon, which passes through a separate compartment in the dorsal carpal ligament, lying in a narrow, oblique groove on the back of the lower end of the radius. It then crosses obliquely the tendons of the Extensores carpi radialis longus and brevis, and is separated from the Extensor brevis pollicis by a triangular interval, in which the radial artery is found; and is finally inserted into the base of the last phalanx of the thumb. The radial artery is crossed by the tendons of the Abductor pollicis longus and of the Extensores pollicis longus and brevis.

  The Extensor indicis proprius (Extensor indicis) is a narrow, elongated muscle, placed medial to, and parallel with, the preceding. It arises, from the dorsal surface of the body of the ulna below the origin of the Extensor pollicis longus, and from the interosseous membrane. Its tendon passes under the dorsal carpal ligament in the same compartment as that which transmits the tendons of the Extensor digitorum communis, and opposite the head of the second metacarpal bone, joins the ulnar side of the tendon of the Extensor digitorum communis which belongs to the index finger.

 

Variations.Doubling; the ulnar part may pass beneath the dorsal carpal ligament with the Extensor digitorum communis; a slip from the tendon may pass to the index finger.

 Nerves.The Brachioradialis is supplied by the fifth and sixth, the Extensores carpi radialis longus and brevis by the sixth and seventh, and the Anconæus by the seventh and eighth cervical nerves, through the radial nerve; the remaining muscles are innervated through the deep radial nerve, the Supinator being supplied by the sixth, and all the other muscles by the seventh cervical.

 Actions.The muscles of the lateral and dorsal aspects of the forearm, which comprise all the Extensor muscles and the Supinator, act upon the forearm, wrist, and hand; they are the direct antagonists of the Pronator and Flexor muscles. The Anconæus assists the Triceps in extending the forearm. The Brachioradialis is a flexor of the elbow-joint, but only acts as such when the movement of flexion has been initiated by the Biceps brachii and Brachialis. The action of the Supinator is suggested by its name; it assists the Biceps in bringing the hand into the supine position. The Extensor carpi radialis longus extends the wrist and abducts the hand. It may also assist in bending the elbow-joint; at all events it serves to fix or steady this articulation. The Extensor carpi radialis brevis extends the wrist, and may also act slightly as an abductor of the hand. The Extensor carpi ulnaris extends the wrist, but when acting alone inclines the hand toward the ulnar side; by its continued action it extends the elbow-joint. The Extensor digitorum communis extends the phalanges, then the wrist, and finally the elbow. It acts principally on the proximal phalanges, the middle and terminal phalanges being extended mainly by the Interossei and Lumbricales. It tends to separate the fingers as it extends them. The Extensor digiti quinti proprius extends the little finger, and by its continued action assists in extending the wrist. It is owing to this muscle that the little finger can be extended or pointed while the others are flexed. The chief action of the Abductor pollicis longus is to carry the thumb laterally from the palm of the hand. By its continued action it helps to extend and abduct the wrist. The Extensor pollicis brevis extends the proximal phalanx, and the Extensor pollicis longus the terminal phalanx of the thumb; by their continued action they help to extend and abduct the wrist. The Extensor indicis proprius extends the index finger, and by its continued action assists in extending the wrist.

VIDEO

2. The Medial Volar Muscles

Palmaris brevis.

Flexor digiti quinti brevis.

Abductor digiti quinti.

Opponens digiti quinti.

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FIG. 427 The muscles of the left hand. Palmar surface. (See enlarged image)

 The Palmaris brevis is a thin, quadrilateral muscle, placed beneath the integument of the ulnar side of the hand. It arises by tendinous fasciculi from the transverse carpal ligament and palmar aponeurosis; the fleshy fibers are inserted into the skin on the ulnar border of the palm of the hand.

 

  The Abductor digiti quinti (Abductor minimi digiti) is situated on the ulnar border of the palm of the hand. It arises from the pisiform bone and from the tendon of the Flexor carpi ulnaris, and ends in a flat tendon, which divides into two slips; one is inserted into the ulnar side of the base of the first phalanx of the little finger; the other into the ulnar border of the aponeurosis of the Extensor digiti quinti proprius.

  The Flexor digiti quinti brevis (Flexor brevis minimi digiti) lies on the same plane as the preceding muscle, on its radial side. It arises from the convex surface of the hamulus of the hamate bone, and the volar surface of the transverse carpal ligament, and is inserted into the ulnar side of the base of the first phalanx of the little finger. It is separated from the Abductor, at its origin, by the deep branches of the ulnar artery and nerve. This muscle is sometimes wanting; the Abductor is then, usually, of large size.

  The Opponens digiti quinti (Opponens minimi digiti) (Fig. 426) is of a triangular form, and placed immediately beneath the preceding muscles. It arises from the convexity of the hamulus of the hamate bone, and contiguous portion of the transverse carpal ligament; it is inserted into the whole length of the metacarpal bone of the little finger, along its ulnar margin.

 

Variations.The Palmaris brevis varies greatly in size. The Abductor digiti quinti may be divided into two or three slips or united with the Flexor digiti quinti brevis. Accessory head from the tendon of the Flexor carpi ulnaris, the transverse carpal ligament, the fascia of the forearm or the tendon of the Palmaris longus. A portion of the muscle may insert into the metacarpal, or separate slips the Pisimetacarpus, Pisiuncinatus or the Pisiannularis muscle may exist.

 

Nerves.All the muscles of this group are supplied by the eighth cervical nerve through the ulnar nerve.

 

Actions.The Abductor and Flexor digiti quinti brevis abduct the little finger from the ring finger and assist in flexing the proximal phalanx. The Opponens digiti quinti draws forward the fifth metacarpal bone, so as to deepen the hollow of the palm. The Palmaris brevis corrugates the skin on the ulnar side of the palm.

 

3. The Intermediate Muscles

Lumbricales.

Interossei.

  The Lumbricales (Fig. 427) are four small fleshy fasciculi, associated with the tendons of the Flexor digitorum profundus. The first and second arise from the radial sides and volar surfaces of the tendons of the index and middle fingers respectively; the third, from the contiguous sides of the tendons of the middle and ring fingers; and the fourth, from the contiguous sides of the tendons of the ring and little fingers. Each passes to the radial side of the corresponding finger, and opposite the metacarpophalangeal articulation is inserted into the tendinous expansion of the Extensor digitorum communis covering the dorsal aspect of the finger.

 

Variations.The Lumbricales vary in number from two to five or six and there is considerable variation in insertions.

  The Interossei (Figs. 428, 429) are so named from occupying the intervals between the metacarpal bones, and are divided into two sets, a dorsal and a volar.

  The Interossei dorsales (Dorsal interossei) are four in number, and occupy the intervals between the metacarpal bones. They are bipenniform muscles, each arising by two heads from the adjacent sides of the metacarpal bones, but more extensively from the metacarpal bone of the finger into which the muscle is inserted. They are inserted into the bases of the first phalanges and into the aponeuroses of the tendons of the Extensor digitorum communis. Between the double origin of each of these muscles is a narrow triangular interval; through the first of these the radial artery passes; through each of the other three a perforating branch from the deep volar arch is transmitted.

  The first or Abductor indicis is larger than the others. It is flat, triangular in form, and arises by two heads, separated by a fibrous arch for the passage of the radial artery from the dorsum to the palm of the hand. The lateral head arises from the proximal half of the ulnar border of the first metacarpal bone; the medial head, from almost the entire length of the radial border of the second metacarpal bone; the tendon is inserted into the radial side of the index finger. The second and third are inserted into the middle finger, the former into its radial, the latter into its ulnar side. The fourth is inserted into the ulnar side of the ring finger.

  The Interossei volares (Palmar interossei), three in number, are smaller than the Interossei dorsales, and placed upon the volar surfaces of the metacarpal bones, rather than between them. Each arises from the entire length of the metacarpal bone of one finger, and is inserted into the side of the base of the first phalanx and aponeurotic expansion of the Extensor communis tendon to the same finger.

  The first arises from the ulnar side of the second metacarpal bone, and is inserted into the same side of the first phalanx of the index finger. The second arises from the radial side of the fourth metacarpal bone, and is inserted into the same side of the ring finger. The third arises from the radial side of the fifth metacarpal bone, and is inserted into the same side of the little finger. From this account it may be seen that each finger is provided with two Interossei, with the exception of the little finger, in which the Abductor takes the place of one of the pair.

  As already mentioned (p. 461), the medial head of the Flexor pollicis brevis is sometimes described as the Interosseus volaris primus.

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The Interossei dorsales of left hand.

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The Interossei volares of left hand.

 

 

Nerves.The two lateral Lumbricales are supplied by the sixth and seventh cervical nerves, through the third and fourth digital branches of the median nerve; the two medial Lumbricales and all the Interossei are supplied by the eighth cervical nerve, through the deep palmar branch of the ulnar nerve. The third Lumbricalis frequently receives a twig from the median.

 

Actions.The Interossei volares adduct the fingers to an imaginary line drawn longitudinally through the center of the middle finger; and the Interossei dorsales abduct the fingers from that line. In addition to this the Interossei, in conjunction with the Lumbricales, flex the first phalanges at the metacarpophalangeal joints, and extend the second and third phalanges in consequence of their insertions into the expansions of the Extensor tendons. The Extensor digitorum communis is believed to act almost entirely on the first phalanges.

Theme 3. THE TOPOGRAPHY OF THE UPPER EXTREMITY, FASCIAE, SYNOVIAL BURSAE AND SHEATHS OF THE UPPER EXTREMITY

Antibrachial Fascia (fascia antibrachii; deep fascia of the forearm).The antibrachial fascia continuous above with the brachial fascia, is a dense, membranous investment, which forms a general sheath for the muscles in this region; it is attached, behind, to the olecranon and dorsal border of the ulna, and gives off from its deep surface numerous intermuscular septa, which enclose each muscle separately. Over the Flexor tendons as they approach the wrist it is especially thickened, and forms the volar carpal ligament. This is continuous with the transverse carpal ligament, and forms a sheath for the tendon of the Palmaris longus which passes over the transverse carpal ligament to be inserted into the palmar aponeurosis. Behind, near the wrist-joint, it is thickened by the addition of many transverse fibers, and forms the dorsal carpal ligament. It is much thicker on the dorsal than on the volar surface, and at the lower than at the upper part of the forearm, and is strengthened above by tendinous fibers derived from the Biceps brachii in front, and from the Triceps brachii behind. It gives origin to muscular fibers, especially at the upper part of the medial and lateral sides of the forearm, and forms the boundaries of a series of cone-shaped cavities, in which the muscles are contained. Besides the vertical septa separating the individual muscles, transverse septa are given off both on the volar and dorsal surfaces of the forearm, separating the deep from the superficial layers of muscles. Apertures exist in the fascia for the passage of vessels and nerves; one of these apertures of large size, situated at the front of the elbow, serves for the passage of a communicating branch between the superficial and deep veins.

Fibrous Sheaths of the Flexor Tendons.After leaving the palm, the tendons of the Flexores digitorum sublimis and profundus lie in osseo-aponeurotic canals formed behind by the phalanges and in front by strong fibrous bands, which arch across the tendons, and are attached on either side to the margins of the phalanges. Opposite the middle of the proximal and second phalanges the bands (digital vaginal ligaments) are very strong, and the fibers are transverse; but opposite the joints they are much thinner, and consist of annular and cruciate ligamentous fibers. Each canal contains a mucous sheath, which is reflected on the contained tendons.

  Within each canal the tendons of the Flexores digitorum sublimis and profundus are connected to each other, and to the phalanges, by slender, tendinous bands, called vincula tendina .There are two sets of these; (a) the vincula brevia, which are two in number in each finger, and consist of triangular bands of fibers, one connecting the tendon of the Flexor digitorum sublimis to the front of the first interphalangeal joint and head of the first phalanx, and the other the tendon of the Flexor digitorum profundus to the front of the second interphalangeal joint and head of the second phalanx; (b) the vincula longa, which connect the under surfaces of the tendons of the Flexor digitorum profundus to those of the subjacent Flexor sublimis after the tendons of the former have passed through the latter.

Fasciæ of the Hand

The muscles of the hand are subdivided into three groups: (1) those of the thumb, which occupy the radial side and produce the thenar eminence; (2) those of the little finger, which occupy the ulnar side and give rise to the hypothenar eminence; (3) those in the middle of the palm and between the metacarpal bones.

 

Volar Carpal Ligament (ligamentum carpi volare).The volar carpal ligament is the thickened band of antibrachial fascia which extends from the radius to the ulna over the Flexor tendons as they enter the wrist.

 

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Transverse section across distal ends of radius and ulna. Transverse Carpal Ligament (ligamentum carpi transversum; anterior annular ligament) is a strong, fibrous band, which arches over the carpus, converting the deep groove on the front of the carpal bones into a tunnel, through which the Flexor tendons of the digits and the median nerve pass. It is attached, medially, to the pisiform and the hamulus of the hamate bone; laterally, to the tuberosity of the navicular, and to the medial part of the volar surface and the ridge of the greater multangular. It is continuous, above, with the volar carpal ligament; and below, with the palmar aponeurosis. It is crossed by the ulnar vessels and nerve, and the cutaneous branches of the median and ulnar nerves. At its lateral end is the tendon of theFlexor carpi radialis, which lies in the groove on the greater multangular between the attachments of the ligament to the bone. On its volar surface the tendons of the Palmaris longus and Flexor carpi ulnaris are partly inserted; below, it gives origin to the short muscles of the thumb and little finger

 

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The mucous sheaths of the tendons on the front of the wrist and digits.

 Transverse section across the wrist and digits.

  

The Mucous Sheaths of the Tendons on the Front of the Wrist.Two sheaths envelop the tendons as they pass beneath the transverse carpal ligament, one for the Flexores digitorum sublimis and profundus, the other for the Flexor pollicis longus. They extend into the forearm for about 2.5 cm. above the transverse carpal ligament, and occasionally communicate with each other under the ligament. The sheath which surrounds the Flexores digitorum extends downward about half-way along the metacarpal bones, where it ends in blind diverticula around the tendons to the index, middle, and ring fingers. It is prolonged on the tendons to the little finger and usually communicates with the mucous sheath of these tendons. The sheath of the tendon of the Flexor pollicis longus is continued along the thumb as far as the insertion of the tendon. The mucous sheaths enveloping the terminal parts of the tendons of the Flexores digitorum have been described on page 449.

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The mucous sheaths of the tendons on the back of the wrist.

 

 Dorsal Carpal Ligament (ligamentum carpi dorsale; posterior annular ligament) is a strong, fibrous band, extending obliquely downward and medialward across the back of the wrist, and consisting of part of the deep fascia of the back of the forearm, strengthened by the addition of some transverse fibers. It is attached, medially, to the styloid process of the ulna and to the triangular and pisiform bones; laterally, to the lateral margin of the radius; and, in its passage across the wrist, to the ridges on the dorsal surface of the radius.

 

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 Dorsal Carpal Ligament (ligamentum carpi dorsale; posterior annular ligament) is a strong, fibrous band, extending obliquely downward and medialward across the back of the wrist, and consisting of part of the deep fascia of the back of the forearm, strengthened by the addition of some transverse fibers. It is attached, medially, to the styloid process of the ulna and to the triangular and pisiform bones; laterally, to the lateral margin of the radius; and, in its passage across the wrist, to the ridges on the dorsal surface of the radius.

 

The palmar aponeurosis

   

The Mucous Sheaths of the Tendons on the Back of the Wrist.Between the dorsal carpal ligament and the bones six compartments are formed for the passage of tendons, each compartment having a separate mucous sheath. One is found in each of the following positions (1) on the lateral side of the styloid process, for the tendons of the Abductor pollicis longus and Extensor pollicis brevis; (2) behind the styloid process, for the tendons of the Extensores carpi radialis longus and brevis; (3) about the middle of the dorsal surface of the radius, for the tendon of the Extensor pollicis longus; (4) to the medial side of the latter, for the tendons of the Extensor digitorum communis and Extensor indicis proprius; (5) opposite the interval between the radius and ulna, for the Extensor digiti quinti proprius; (6) between the head and styloid process of the ulna, for the tendon of the Extensor carpi ulnaris. The sheaths lining these compartments extends from above the dorsal carpal ligament; those for the tendons of Abductor pollicis longus, Extensor brevis pollicis, Extensores carpi radialis, and Extensor carpi ulnaris stop immediately proximal to the bases of the metacarpal bones, while the sheaths for Extensor communis digitorum, Extensor indicis proprius, and Extensor digiti quinti proprius are prolonged to the junction of the proximal and intermediate thirds of the metacarpus.

 

 Palmar Aponeurosis (aponeurosis palmaris; palmar fascia) invests the muscles of the palm, and consists of central, lateral, and medial portions.

  The central portion occupies the middle of the palm, is triangular in shape, and of great strength and thickness. Its apex is continuous with the lower margin of the transverse carpal ligament, and receives the expanded tendon of the Palmaris longus. Its base divides below into four slips, one for each finger. Each slip gives off superficial fibers to the skin of the palm and finger, those to the palm joining the skin at the furrow corresponding to the metacarpophalangeal articulations, and those to the fingers passing into the skin at the transverse fold at the bases of the fingers. The deeper part of each slip subdivides into two processes, which are inserted into the fibrous sheaths of the Flexor tendons. From the sides of these processes offsets are attached to the transverse metacarpal ligament. By this arrangement short channels are formed on the front of the heads of the metacarpal bones; through these the Flexor tendons pass. The intervals between the four slips transmit the digital vessels and nerves, and the tendons of the Lumbricales. At the points of division into the slips mentioned, numerous strong, transverse fasciculi bind the separate processes together. The central part of the palmar aponeurosis is intimately bound to the integument by dense fibroareolar tissue forming the superficial palmar fascia, and gives origin by its medial margin to the Palmaris brevis. It covers the superficial volar arch, the tendons of the Flexor muscles, and the branches of the median and ulnar nerves; and on either side it gives off a septum, which is continuous with the interosseous aponeurosis, and separates the intermediate from the collateral groups of muscles.

  The lateral and medial portions of the palmar aponeurosis are thin, fibrous layers, which cover, on the radial side, the muscles of the ball of the thumb, and, on the ulnar side, the muscles of the little finger; they are continuous with the central portion and with the fascia on the dorsum of the hand.

  The Superficial Transverse Ligament of the Fingers is a thin band of transverse fasciculi it stretches across the roots of the four fingers, and is closely attached to the skin of the clefts, and medially to the fifth metacarpal bone, forming a sort of rudimentary web. Beneath it the digital vessels and nerves pass to their destinations.

Topography of the upper limb

Axillary fossa is deepening between lateral surface of the chest and medial surface of the arm. It is bordered at the front by fold of skin (lower margin of the pectoral major level), from behind - by fold of skin (lower margin of the latissimus dorsi level).

Axillary cavity contains adipose tissue, vessels, lymphatic nodes, and nerves. It is bordered at the front by pectoral major and minor muscles; from behind - by latissimus dorsi, subscapular and major teres muscles; medially by anterior serratus muscle; laterally surgical neck of the humerus and biceps muscles.

There are three trigones in anterior wall of axillary cavity:

1.   clavicul-pectoral trigone bordered by lower margin of clavicle and upper margin of pectoral minor muscle;

2.   pectoral trigone - bordered by upper and lower margin of pectoral minor muscle;

3.   subpectoral trigone - bordered by lower margins of pectoral minor and pectoral major muscles.

There are two orifices in posterior wall of axillary cavity:

1. Trilaterum foramen - bordered by subscapular, teres major muscles and long head of triceps brachii muscle, circumflexa scapulae artery passes through it;

2. Quadrilaterum foramen placed laterally from trilaterum foramen and bordered by the same muscles and surgical neck of humerus, circumflexa humeri artery passes through it.

Fascia which covers deltoid muscle, passes into arm (brachial fascia). It forms sheathes for muscle, also medial and lateral intermuscular septa (partitions) of the arm that border anterior and posterior groups of muscles.

Medial bicipitis sulcus placed medially between biceps brachii muscle and brachial muscle. There are vessels and nervous bundle runs here. Laterally one can find - lateral bicipitis sulcus, where cephalic vein passes.

Canal of radial nerve positioned between sulcus in humerus and triceps brachii where radial nerve and deep brachial artery and vein pass.

Diamond-shaped cubital fossa located between arm and forearm on front surface. It bordered from below by brachiradialis muscle and pronator teres muscle. It bordered from above by brachial muscle.

Bursae of the Shoulder

A "bursa" is a fluid-filled sac, lined with synovial membranes, that occurs near a joint. There are several bursae associated with the shoulder joint. The major ones include the "subscapular bursa," located between the joint capsule and the tendon of the subscapularis muscle; the "subdeltoid bursa," between the joint capsule and the deep surface of the deltoid muscle; the "subacromial bursa," between the joint capsule and the under surface of the acromion process of the scapula (shoulder blade); and the "subcoracoid bursa," between the joint capsule and the coracoid process of the scapula. Of these, the subscapular bursa usually is continuous with the synovial cavity of the joint cavity, and although the others do not communicate with the joint cavity, they may be connected to each other. All joints contain bursa, however, the shoulder has eight different bursae (the most of any joint in the body).

Fasciae of the upper limb

Brachial fascia passes in forearm as antebrachial fascia, which forms sheathes for all muscle of forearm. In wrist it thickens and makes on anterior surface retinaculum flexorum.

Last attaches laterally to the radial carpeal eminence that formed by tubercles of scaphoid and trapezius bones and medially - t ulnar carpeal eminence that formed by pisiform bone and hamulus ossis hamati.

Carpeal canal disposed under retinaculum flexorum where tendons of muscles pass from forearm into wrist. Retinaculum extensorum placed on back surface under which 6 osseofibrous canals dispose. There are tendons of extensor muscles:

1.   in first canal (starting from the radial side) - tendons of Abductor pollicis longus and Extensor pollicis brevis pass;

2.   in second canal - tendons of Extensor carpi radialis longus and Extensor carpi radialis brevis pass;

3.   in third canal - tendon of Extensor pollicis longus passes;

4.   in fourth canal - tendons of Extensor digitorum and Extensor indicis pass;

5.   in fifth canal - tendon of Extensor digiti minimi passes;

6.   in sixth canal - tendon of Extensor carpi ulnaris pass.

Tendons of flexor muscles that pass thorugh carpeal canal are covered by synovial membrane which form such sheathes:

common synovial vagina of flexors covers tendons of musculus flexor digitirum superficialis and profundus till middle of palm (in little finger it passes till nail phalanx);

synovial vagina of tendon for musculus flexor pollicis longus covers tendon of same name muscle;

synovial vaginae for tendons of musculus flexor digitirum superficialis and profundus (of II, IV fingers) - covers tendons of these muscles from base of proximal phalanx till top of the distal phalanx.

There are three grooves between anterior forearm muscles where vessels and nerves disposed:

Radial sulcus - between brachioradial muscle and musculus flexor carpi radialis;

Median sulcus - between musculus flexor carpi radialis and musculus flexor digitirum superficialis;

ulnar sulcus - between musculus flexor carpi ulnaris and musculus flexor digitirum superficialis.

Antebrachial fascia passing in hand makes fascia of manus that has palmar and dorsal parts. Palmar part subdivided into superficial sheet and deep sheet. Deep sheet forms the sheathes for muscles of the hand. Superficial sheet makes up triagle-shaped palmar aponeurosis.

Prepared by

Reminetskyy B.Y.