HAND AND WRIST

Key Information
The boundaries of the carpal tunnel are:
Floor - the carpal bones.
Roof - flexor retinaculum.
Attachments of the flexor retinaculum are: proximally - tubercle of scaphoid and pisiform; distally - trapezium and hook of
the hamate.

The carpal tunnel contains the median nerve and 10 tendons:

Flexor digitorum superficialis (4)
Flexor digitorum longus (4)
Flexor carpi radialis
Flexor pollicis longus

The boundaries of the anatomical snuff box are:

Base - Bones - base of 1st metacarpal, trapezium, scaphoid, styloid process of radius
Ulna/medial - extensor pollicis longus tendon
Radial/lateral - abductor pollicis longus and extensor pollicis brevis tendons
Roof - fascia and skin

It contains:
Radial artery
Radial nerve (terminal branches)
Cephalic vein origin

The intrinsic muscles of the hand are supplied by the ulnar nerve. The exceptions to this are the LOAF muscles, which
are supplied by the median nerve.

Can you name the carpal bones?

There are two rows of carpal bones, from radial to ulnar:
Proximal row - scaphoid, lunate, triquetral and pisiform
Distal row - trapezium, trapezoid, capitate and hamate

What are the boundaries of the carpal tunnel?

1
The floor of the carpal tunnel is formed by the carpal bones.
The roof is formed by the flexor retinaculum.
The attachments of the flexor retinaculum are:
Proximally - tubercle of scaphoid and pisiform;
Distally - trapezium and hook of the hamate.
The proximal surface marking of the flexor retinaculum is the distal skin crease of the wrist.

What are the contents of the carpal tunnel?

The carpal tunnel contains the median nerve and 10 tendons:
Flexor digitorum superficialis (4)
Flexor digitorum profundus (4)
Flexor carpi radialis
Flexor pollicis longus
Remember: the ulnar nerve and artery run in their own tunnel - the canal of Guyon.

What are the boundaries of the anatomical snuff box?

Base = Bones - base of 1st metacarpal, trapezium, scaphoid, styloid process of radius
Ulna/medial - extensor pollicis longus tendon
Radial/lateral - abductor pollicis longus and extensor pollicis brevis tendons
Roof - fascia and skin

What are the contents of the anatomical snuff box?

The contents of the anatomical snuff box from deep to superficial are:
Radial artery
Radial nerve (terminal branches)
Cephalic vein origin

2
What is the significance of the anatomical snuff box?
Tenderness may be indicative of a scaphoid fracture that may not be obvious on early X-ray - the distal-to-proximal
arrangement of the blood supply renders the scaphoid susceptible to avascular necrosis, so it is important that injuries
are recognised and treated early.

Can you describe the nerve supply to the small muscles of the hand?
The intrinsic muscles of the hand are supplied by the ulnar nerve - the best way to test this is by abduction of the fingers
(testing the dorsal interossei).
The exceptions to this are the LOAF muscles, which are supplied by the median nerve:
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis

The median nerve can be tested by asking the patient to place their hand palm up and point the thumb at the ceiling. Ask
them to resist you pushing it back to neutral.

What actions are performed by the interossei and lumbricals?

The actions of the interossei are best remembered by PAD and DAB:
Palmar interossei (of which there are 4) ADduct the fingers
Dorsal interossei (of which there are 5) ABduct the fingers.
The lumbricals aid in flexion of the MCPJs, with extension of the IPJs.

Describe the arrangement of the attachments of the flexor digitorum profundus and superficialis tendons.
The FDP muscle flexes the tips of the digits at the distal interphalangeal joints, each tendon inserting into the base of a
distal phalanx.
The FDS muscle flexes the digits at the proximal interphalangeal joints - the tendons split to allow through the FDP
tendon, inserting into the base of the middle phalanx.

What mechanisms prevent bow-stringing of the flexor tendons?

Several pulleys, consisting of thickenings of fascia, prevent bow-stringing by anchoring the flexor tendons to the bony
skeletons and allowing smooth sliding beneath. Proximally at the wrist there is the flexor retinaculum, and more distally

3
there are 5 annular pulleys and 3 cruciate pulleys.

How many compartments are there in the extensor retinaculum of the wrist?
There are six compartments in the extensor retinaculum. From radial to ulnar they are:
1. Extensor pollicis brevis and abductor pollicis longus
2. Extensor carpi radialis longus and extensor carpi radialis brevis
3. Extensor pollicis longus
4. Extensor indicis proprius and extensor digitorum communis
5. Extensor digiti minimi
6. Extensor carpi ulnaris