CLINICALSYMPOSIA

e\

VOLU\IE 22 NU,N,fBER 3 S.qPTEA,TBER-OCTOBEN-NOVEMBER.DECEMBER 1970

His parents say:"U nmanageable, clu ffi sy, destructive..."

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Physicians would say:

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v o r u r r r 2 2S E P T E M B E R .NOVEMBER.DI

Whatever the terms usedto ident i f y the a t f l i c t ion , manyinvesi igators conf i rm thatR i ta l in , as an ad junc t tospec ia l educat iona l measures andspec i I i c paren ta l a t t i tudes ,he lps cont ro l the ch i ld 's hvper -a r : t i v i t v i n c r e a s e h i s v e r b a lq v L , v , L t

produc t iv i t y and a t ten t ion span,improve h is behav iour andlearn ing ab i l i t ies .. F B P - F u n c i i o n a l B e h a v i o u r P r o b l e m s

NIBD - lV in ma l Bra n Dys func t ionl \ lCD * M n ima l Cerebra l Dys func t ion

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CLIi\ICALSYMPOSIA

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C I B A

v o L U M E 2 2 N u n a n r n 3

:lllEr\11ER - ocroBER l970

NovEMBER-DECEMBER '

SURCICAL ANATOMY OF THE HAND

ErnestW. Lampe, M.D.

Skin and Subcutaneous Fascia of the Hand

Blood and Lymph Vessels

Clinical Importarice of Osseous Blood Supply

Veins

Lymph Vessels

Nerves of the Hand

Muscles of the Hand

Tendons, Vessels, and Nerves at the Wrist

Intrinsic Muscles.of the Hand

Interosseous Muscles

Lumbrical Muscles

Radial, Median, and Ulnar Nerve Lesions

Ligaments of the Hand

Tendon and Muscle Sheaths of the Hand

Subtendinous Space

Lumbrical Muscle Sheaths

Thenar and Midpalmar Sppces

Surgical Incisions

Treatment of lland Injuribs

Published solely in tlce inte{est of the medicalCIBA COMPANY LIMITED,.

DORVAL, QUE,

l. Hmold Wabom, M.D,, Editor

COPYRIGIIT I97O EY CIBA COMPANY LIMITED

PRINT'ED IN CANADA

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profession by

S U R G I C A L A N A T O M Y O F T H E H A N DWith Special Reference to Infections and Trauma

E R N E S T . w . L A M P E , M . D . ( 1 8 9 6 - 1 9 6 6 )

Eorron's Norr: Dr. Lampe, author of this masterpiece which ffrst appeared in Cr,rNrcar SyMposr.q. in195I, at the time of his death was Associate Attending Surgeon at the New York Hospital, EmeritusClinical Professor of Anatomy, Cornell University Medical College, and Visiting Surgeon at BellevueHospital. Of all the honors received by Dr. Lampe the most touching appraisal of the man was madeby his own students in dedicating their 1962 Yearbook:

"To Ernest W. Lampe, teacher, who conscientiously clariffed the intricacies of anatomy,made beautiful its relations, and taught by example, the integrity, wisdom, and kindlinessof a true physician."

Although Ernest Lampe has now departed, his

Illustrations by Fner.lx H. Nnrrrn, M. D,

Chemotherapy and better early care

have decreased the incidence of serious

infections of the hand. Still, a consider-

able number become sufficiently severe to

warrant surgery. Add to these the vastly

increased number of traumatized hands

that demand repair, and it becomes quiteevident that surgery of the hand is still an

important part of surgical therapeutics.

Other qualifications being equal, the sur-

geon with the sounder knowledge of the

surgical anatomy of the hand shouid

achieve the better end-results.

While nothing especially new is pre-

sented in th is monograph, we have

attempted to emphasize, by figures, dia-

grams, and text, certain anatomical struc-

tures and relationships, which may be

found helpful to the surgeon called upon

to treat a serious tendon-sheath-space

infection or a badly lacerated hand.

SKIN AND SUBCUTANEOUS FASCIA

OF THE HAND

Figures I,2,3, and 25 demonstrate the

important structural difierences between

the subcutaneous tissue of the palm and

that of the dorsum of the hand.

66

work will live to benefft many future generations.

In the palm, innumerable minute, but

strong, fibrous fasciculi extend from the

palmar aponeurosis to the skin. Thesehold the skin close to the underlying pal-mar aponeurosis , permi t t ing compar-atively little sliding movement of oneupon the other. Also, these thread-likefibrous strands divide the subcutaneousfat into small, irregular masses. Numer-ous, minute blood vessels pass throughthis subcutaneous tissue to the derma.

Clinically, it is important to rememberthe relationship of the fibrous fasciculi to

the skin, fat, and blood vessels.InDupuy-

tren s contracture,hypertrophy and hyper-

plasia of this fibrous tissue result in ulti-

mate displacement of the fat masses and

partial obliteration of the blood vessels,thereby interfering markedly with the

nutrition of the skin. Obviously, this pointsto the wisdom of early surgical excision

of the palmar aponeurosis in Dupuytren's

contracture.

Contrast the tight relationship of the

palmar aponeurosis, subcutaneous tissue,

and skin of the palm with the looseness of

these structures on the dorsum of the

hand! Figures 3 and 25 show the loose-

ness of areolar tissue which creates the

so-called dorsal subcu

This tissue is so lar

skin grasped betweerindex finger can be elemeters off the under\

fact, it is so loose thatarated readily from 1

blunt dissection - qrthe palm where this m

sharp dissection. Thesory nerves, veins, andthis loose areolar layrin Figure 3.

It is important to erof the lymph from thrthe fingers, web-areathenar eminences florlymph channels andthe loose areolar laye:the hand (see pages i

This anatomic facl

marked lymphedema

quently seen on the bawhen the focus of inftmar aspect of the finge

thenar or thenar areaunwitting one mistake

of such a swollen hanrfinds lymphedema insl

Dorsal Deep Fascia

On the dorsum of Ifascia and extensor tethe roof for Ihe dorspace (Figures 3, 17, Jbarrier formed by thrand interosseous musc

of flow and locationthis space is not very Iin hand infections. Mrlitis and direct penetrby a sharp, contaminecauses for those rare arfound in this space.

C L I N I C A L S Y M P O IC I B A

so-called dorsal subcutaneous space.This tissue is so lax that a fold of the

skin grasped between one's thumb andindex finger can be elevated several centi-meters ofi the underlying deep fascia. Infact, it is so loose that the skin can be sep-arated readily from the deep fascia byblunt dissection - quite difierent fromthe palm where this must be done by verysharp dissection. The course of the sen-sory nerves, veins, and lymphatics throughthis loose areolar layer is clearly shownin Figure 3.

It is important to emphasize that mostof the lymph from the palmar aspects ofthe fingers, web-areas, hypothenar andthenar eminences fows into myriads oflymph channels and lacunae located inthe loose areolar layer on the dorsum ofthe hand (see pages 76 and 80).

This anatomic fact accounts for themarked lymphedematous swelling fre-quently seen on the back of the hand evenwhen the focus of infection is on the pal-mar aspect of the finger, web-space, hypo-thenar or thenar area. Occasionally, theunwitting one mistakenly incises the backof such a swollen hand and to his dismayfinds lymphedema instead of pus.

Dorsal Deep Fascia

On the dorsum of the hand, the deepfascia and extensor tendons fuse to formthe roof for the dorsal subaponeuroticspace (Figures 3, 17, 25). Because of thebarrier formed by the metacarpal bonesand interosseous muscles and the mannerof flow and location of the lymphatics,this space is not very frequently involvedin hand infections. Metacarpal osteomye-litis and direct penetration of the spaceby a sharp, contaminated instrument arecauses for those rare accumulations of pusfound in this space,

C L I N I C A L S Y M P O S I A

Palmar Deep Fascia

Figures I and 2 show the intimate con-tact of the deep fascia to the thenar andhypothenar groups of muscles. This rela-tionship prevents formation of a spaceover these muscles within which pus mayaccumulate.

The central, triangular-shaped part ofthe palmar aponeurosis has several ana-tomical features worthy of mention. InDupuytrens contracture, the clinical sig-nificance of its attachment to the dermaand its relationship to the subcutaneousfat and blood vessels have already beenmentioned. Figures on page 73 show thatthe proximal end is continuous with thetendon of the palmaris longus muscle. Itis this attachment that enables the pal-maris longus muscle to assist in flexion ofthe hand.

Figures I, 2, 4, and 25 demonstrate theprotective thickness of the central tri-angular part and also the manner of itsfusion medially and laterally with thedeep fascia covering the hypothenar andthenar muscles, respectively. An under-standing of this relationship helps onerealize why the great majority of handinfections, excluding fingers, are found inthe hollow of the palm between or distalto the hypothenar and thenar eminences.

At the base of the aponeurotic triangle,the interlacing fasciculi of the superficialtransverse metacarpal ligament add pro-tection to the underlying digital vesselsand nerves (Figure 2). Fasciculi extendto the proximal phalanges to fuse with thefibrous annular tendon sheath on its pal-mar, medial, and lateral aspects. Theseinsertions enable the palmaris longusmuscle to help in flexing the proximalphalanges.

In the distal part of the palm, septa

67

extend from the deep aspect of the palmar

aponeurosis to the deep transverse palmar

ligament forming the sides of annular

fibrous canals for the passage of the

ensheathed flexor tendons and lumbrical

muscles as well as blood vessels and

nerves ( Figures 4, 5, 25).

The semidiagrammatic cross section on

page 89 shows a septum extending from

the palmar aponeurosis to the third meta-

carpal. Frequently, but not always, this

septum separates the thenar space or

bursa from the midpalmar space or bursa.

The beginnings of the other less well-

developed septa are also shown in this

figure. Since this section is proximal to

the deep transverse metacarpal ligament,

located at the distal ends of the metacar-

pal bones, these septa appear unattached

on their deep aspect. However, iust distal

to the ends of the midpalmar and thenar

spaces, they are actually attached to thedeep transverse metacarpal ligament.

BLOOD AND LYMPH }'ESSELS

Figures 4, 6, and 7 show how the radialand ulnar arteries terminate by dividinginto superficial and deep branches. Theformer anastomose in the palm to formthe superficial palmar arterial arch, thelatter to form the deep arch.

A line drawn across the palm at the levelof the distal border of the fully abductedthumb marks the approximate location ofthe superffcial arterial arch. This is shownas a broken line in Figure 6. The deeparch is a ftnger's breadth proximal.

The pulsation of the ulnar artery canusually be felt just lateral to the pisiformbone. Immediately distal to this pointthe artery divides into its larger branchwhich forms most of the superficialarch and the smaller branch which forms

68

the lesser part of the deep palmar arch.

Just proximal to the pisiform bone theulnar artery gives ofi volar and dorsal car-pal branches which unite with the volarand dorsal branches of the radial artery toform the arterial wristlet about the car-pal bones. Perforating branches passingbetween the proximal ends of the middlemetacarpal bones connect the deep pal-mar arch with the dorsal carpal arch, asshown in Figure 17. The latter sends smallbranches to the phalanges.

The pulsation of the radial artery is usu-ally palpated near the proximal volarcarpal skin crease. Here the superficialbranch arises to continue distally over orthrough the thenar eminence to the palmto complete the formation of the super-ffcial palmar arterial arch (Figures onpage 7B).

The much larger, deep radial branch,whose pulsat ions can be fel t in theanatomical snuffbox, Figures 17 and 20,passes under the "snuffbox" tendons andplunges between the two heads of the firstdorsal interosseous muscle to reach thepalm where it forms the greater part ofthe deep palmar arch, Figure 6.

It is to be remembered that the super-ftcial arterial arch is much larger andmore important than the deep arch.

The superficial arch gives ofi digitalbranches which bifurcate into phalangealbranches about a ffnger's breadth proxi-mal to the web-border of the hand, Fig-ures 6 and 7. The superficial arch and itsdigital branches are immediately deep tothe tough central part of the palmaraponeurosis and are superftcial to thebranches of the median and ulnar nerves.This relationship to the nerves is reversedin the fingers ( Figures 6,7 , 16) .

As shown in Figure 6, the rnetacarpalbranches of. the deep arch empty into the

digital branches of. tjust proximal to their

phalangeal arteries,

CLINICAL IMPORTA

BLOOD S'

The lunate bonemost frequently dislor

pal bones. Therefore,remember a few poi:supply. As shown in lfrom the dorsal and rreach the bone via iligaments from the rasurvive only if one li1

good results can bereduction is efiected.atrophic necrosis is tlments have been rup

Since the naoicularmost frequently fractbones, it is importantabout two-thirds of tvessels are evenly enrexpect survival of b<some chance for unio:third, however, so malsels are located neareother that necrosis ismeagerly supplied fra

A felon may cause rend of the terminal pJbiotics and supportiveistered very early, edtcause thrombosis of srbranches of the digitrinterfere sufficiently Iply of the bony tuft 1eventuate in its necromatically shows thesepta in the palmar 1phalanx - especially :terminal vessels are fo

C L I N I C A L S Y M P OC I B A

l

di,gi.tal branches of the superficinl arch

just proximal to their bifurcation into the

phalangeal arteries.

CLINICAL IMPORTANCE OF OSSEOUS

BLOOD SUPPLY

The lunate bone (semilunar) is the

most frequently dislocated of all the car-

pal bones. Therefore, it is important to

remember a few points about its blood

supply. As shown in Figure I0, branches

from the dorsal and volar carpal arteries

reach the bone via its dorsal and volar

ligaments from the radius. The bone can

survive only if one ligament is torn, and

good results can be expected if early

reduction is efiected. On the other hand,

atrophic necrosis is the rule if both liga-

ments have been ruptured (Figure 12 ).Since the nnrsicular (scaphoid ) is the

most frequently fractured of the carpal

bones, it is important to remember that in

about two-thirds of the cases the blood

vessels are evenly enough distributed to

expect survival of both fragments with

some chance for union. In the remaining

third, however, so many of the blood ves-

sels are located nearer one end than the

other that necrosis is apt to occur in the

meagerly supplied fragment ( Figure t3 ).A felon may cause necrosis of the distal

end of the terminal phalanx. Unless anti-

biotics and supportive therapy are admin-

istered very early, edema and toxins will

cause thrombosis of some of the terminal

branches of the digital arteries and thus

interfere sufficiently with the blood sup-

ply of the bony tuft (Figures 14, 16 ) to

eventuate in its necrosis. Figure 15 sche-

matically shows the numerous fibrous

septa in the palmar part of the terminal

phalanx - especially its distal half. The

terminal vessels are found in these irregu-

C L I N I C A L S Y M P O S I A

Iarly formed expansionless compartments.

It does not require much edema and toxin

to cause early thrombosis with subse-

quent necrosis of the tuft of the phalanx.

VEINS

The hand, like the remainder of the

upper extremity, is drained by two sets of

veins: a superficial group located on the

superficial fascia and a deep set associ-

ated with the arteries. These are illus-

trated in Figures 3, 4, 8, and 9.

The superficial oenous systern is the

more important of the two sets because it

is the larger, and most of the ffnger and

hand lymphatics accompany its tribu-

taries (Figures 3, 8, 9 ). A few small veins

are found in the tight superficial or sub-

cutaneous fascia of the palm and palmar

aspects of the fingers. However, they com-

pare neither in size nor number with those

located in the loose areolar subcutaneous

tissue of the dorsum of the hand and

fingers. While Figure 3 ofiers an idea of

the venous arrangement on the dorsum of

the hand, one needs but hang the hand at

the side for a moment to demonstrate

quite clearly the dorsal venous arch. This

arch receives digital veins from the fingers

and frequently becomes continuous with

the cephalic and basilic veins on the

radial and ulnar borders of the wrist. A

glance at the volar aspect not uncom-

monly reveals the distal end of the median

antebrachial vein near the carpal creases,

where it receives the few, small and usu-

ally invisible, superficial palrnar veins.

The above-mentioned veins - cephalic,

basilic, and medtan antebrachi.al - con-

tinue proximad; and they, with their trib-

utaries, make up the superficial venous

drainage of the upper extremity.

The deep oenous return is not difficult

69

to review if one recalls that the very small

digital veins, helping to drain the fingers,

empty into small superficial and deep

venous arches associated respect ive ly

with the superficial and deep arterial

arches, Figures 4 and 6. These two venous

arches help form the venae comites which

accompany the radial and ulnar arteries;

and they, with their tributaries, make up

the deep venous drainage of the forearm.

At the elbow the radial and ulnar venae

comites unite to form the venae comites

of the brachial artery, and they in turn

unite with the basilic vein at the pectoralfold to form the axillary vein.

In the hand, forearm, and arm the

superficial and deep sets of veins anasto-

mose with each other by means of a

variable number of communicating or

perforating veins.

LYMPII IIESSELS

If one knows the venous drainage of the

hand, one can easily visualize the lymph

drainage because, generally speaking, the

lymph vessels follow the veins, having

originated from the same mesenchymal

tissue. This implies the presence of a

superficial and deep set of lymph vessels

corresponding to the superficial and deep

sets of veins.

S up erfici.al LV "rph

Y e s s els

While some of the proximal phalangeal

and web-area lymph vessels proceed

palmward, most of them head for the dor-

sum of the fingers and hand (Figure 9).

Most of the lymph from the thenar and

hypothenar areas fows toward the vessels

and lacunae in the subcutaneous loose

areolar tissue - the so-called dorsal sub-

cutaneous space. This should remind one

again of the reason for the frequent swell-

70

ing (lymphedema) of the dorsum of the

hand in the presence of an infection onthe palmar aspect of a finger, web-area,

or edge of the thenar or hypothenar

eminence.

Most of the lymph from the dorsumleaves via lymph vessels accompanyingthe cephalic and basilic veins. This is

shown by the black arrows in Figure 3. In

theory at least, bacteria or tumor cellsfrom a focus on the thumb or index finger

have easier access to the thoracic ducts,since they tend to follow the cephalicvein. The lymph gland in the deltopec-toral triangle is the first sizable node

encountered by the lymph channels fol-lowing this vein. Contrast this relatively

gland-free pathway with the gland-studded route along the basilic and axil-

lary veins (Figure 8).

Deep LymphVessels

Figure 9 shows schematically how most

of the central palmar lymph vessels pro-ceed deeply to join the lymph vessels

associated with the superficial and deep

venous arches. From here lymph channels

follow the venae comites of the radial and

ulnar arteries.

NERVES OF THE IIAND

The median, ulnar, and radial nerves

furnish most of the motor and sensory con-

trol of the hand. The dorsal antebrachial

cutaneous and lateral antebrachial cuta-

neous nerves assist variably in supplying

sensory nerves.

Motor Neraes

The intrinsic muscles of the hand are

controlled by the ulnar and median nerves

(Figures 5, 6,'1 ,30 ). Since these muscles

are not the sole manipulators of the hand,

the radial nerve, whiching the extrinsic musclconsidered.

Ordinarily, the musclor volar-medial aspect creferred to as the volaand those on the posteriside as the dorsal groutell nothing more than t

It might be even mor,functional names werebecause they would alwwhat these important nFor example: It is kno'rof the hand (flexors culnaris ), Figures 21 andfingers (flexors digitorrprofundus), Figure 24; r(pronators radii teres ar:located in this so-callermuscles. Would it not brtical to think of the grrpronetor group-anamein a general way what t

The same applies to tlmuscles consisting of thrhand (extensors carpi rabrevis and extensor carp26; the extensors of thlanges and assistant rmiddle phalanges (extrcommunis, indicis prolquinti proprius); the extrtor of thumb (extensors 1longus and abductor pollures 20 and,26r and ffnisupinator of the forea:muscle (the supinator nto as the assistant suoinbiceps muscle, suppliedcutaneous nerve, is the ntant supinator), Therefcthe whole dorsal forearrcles the extensor-assistan

C L I N I C A L S Y M P O S IC I B A

the radial nerve, which assists in supply-ing the extrinsic muscles, must also beconsidered.

Ordinarily, the muscles of the anterioror volar-medial aspect of the forearm arereferred to as the volar forearm group,and those on the posterior or dorsolateralside as the dorsal group - names whichtell nothing more than their location.

It might be even more helpful if broadfunctional names were applied to thembecause they would always remind one ofwhat these important muscle groups do.For example: It is kno'rn that the fexorsof the hand (fexors carpi radialis andulnaris), Figures 21 and 28; flexors of thefingers (flexors digitorum sublimis andprofundus), Figure 24; and the pronators(pronators radii teres and quadratus) arelocated in this so-called volar group ofmuscles. Would it not be a bit more orac-tical to think of the group as the nu*or-pronator group-a name which would tellin a general way what these muscles do?

The same applies to the dorsal group ofmuscles consisting of the extensors of thehand (extensors carpi radialis longus andbrevis and extensor carpi ulnaris), Figure26; the extensors of the proximal pha-langes and assistant extensors of themiddle phalanges (extensors digitorumcommunis, indicis proprius, and digitiquinti proprius); the extensors and abduc-tor of thumb (extensors pollicis brevis andlongus and abductor pollicis longus ), Fig-ures 20 and 26; and finally, the assistantsupinator of the forearm or supinatormuscle (the supinator muscle is referredto as the assistant supinator because thebiceps muscle, supplied by the musculo-cutaneous nerve, is the much more imDor-tant supinator ), Therefore, why not callthe whole dorsal forearm group of mus-cles the extensor-assistant supinator group

C L I N I C A L S Y M P O S I A

- supplied by the extensor-assistant supi-nator nerve - the functional name for theradial nerceP

In his first course in surgical diagnosis,the junior medical student learns that theusual test for ulnar neroe palsy is tospread and approximate the fingers; andthe more common test for median nerzepalsy is to approximate successively thetip of the thumb to the tips of the fingers.

The ulnar nerve controls certain mus-cles which flex the hand and fingers(flexor carpi ulnaris and the ulnar half ofthe flexor digitorum profundus ) as well asthe intrinsic muscles of the hand exceptthose in the thenar eminence and twoadjacent lumbrical muscles.

Since the interosseous muscles whichspread and approximate the fingers areexclusively controlled by the ulnar nerve,this action of the interossei can serve as atest of ulnar nerve function. If the nerveis damaged, one will have difficulty inholding a piece of paper between adja-cent fingers which are fully extended.Thus, the action of these muscles gives tothe ulnar nerve a logical functionalname:the finger -spreader-approximnt or nerle.

The median nerve controls the wholeflexor-pronator group except one and one-half muscles ( the ulnar nerve controlsonly the flexor carpi ulnaris and ulnar halfof the flexor digitorum profundus), andbecause the median nerve innervates theIateral two lumbrical muscles and thethenar eminence muscles whose opponensmuscle is fhe important muscle in approx-imating the thumb-tip successively to thefinger tips, it seems reasonable to givethe median nerDe a functional nu*",1h"

flexor - pron&tor - thumb - finger - approxi-rnator nerDe - a rather long name, but itsummarizes the chief motor r6le of themedian nerve.

7T

Sensory Nenses

Figure 18 shows diagrammatically a

palmar view of the hand with the median

nerae stpplying the median or central

palmar area and the palmar surfaces of

the lateral three and one-half fingers; Fig-

ure 19, a dorsal view, charts the mediannerve distribution to the dorsum of the

distal two phalanges of the lateral three

and one-half fingers.

Note how the ulnnr neroe supplies sen-sory nerves to the volar and dorsal aspects

of the medial third of the hand and the

volar and dorsal aspects of the medial one

and one-half f ingers, Figures 3,7,17, 18,

and 19.

The radfuI nen)e co\veys sensation from

the lateral two-thirds of the dorsum of thehand and a portion of the thenar emi-nence area, as well as from the dorsum ofthe proximal phalanges of the lateral threeand one-half fingers.

Variations of the sensory distribution ofthe above three nerves are quite common.For example, on the palmar surface, themedian nerve may supply only the centralthird of the palm and the skin of two andone-half fingers, with the ulnar nerve

innervating the medial half of the palm

and two and one-half ffngers. Further-

more, the lateral antebrachial cutaneous(volar branch of musculocutaneous) occa-

sionally extends its control as far as the

web-area of the thumb, index, and middle

fingers. On the dorsum, the ulnar nerve

may give sensory nerves to the medialhalf of the dorsum of the hand as well asto the dorsum of two and one-half ffngers.

This leaves the radial nerve offering sen-sory nerves to only the lateral half of thedorsum of the hand and proximal pha-langes of two and one-half fingers. Occa-

sionally, the dorsal branch of the medial

72

antebrachial cutaneous nerve may extenddistally almost to the web-area betweenthe fifth, fourth, and third fingers; andsometimes the dorsal antebrachial cuta-neous nerve may reach the web-areas be-tween the second, third, and fourth fingers.

Figures 1 and 7 show the median andulnar nerves in the distal forearm givingof f thei r palmar cutaneous brancheswhich are destined to supply the skin ofthe proximal palm. The median nerve

passes under the tough transverse carpalligament and divides into (a ) three lat-eral branches - two supplying either sideof the thumb and the third to the lateralaspect of the index finger, and (b ) twomedial branches - one dividing to inner-vate adjacent surfaces of the index andmiddle finger and the other to the adia-cent aspects of the third and fourth fingers.

It is of considerable clinical importanceto remember that the main muscularbranch of the median nerve arises fromthe lateral cutaneous branch to the thumbjust distal to the transverse carpal liga-ment, Figure 7. Observe that en route tothe thenar eminence and its muscles (thefexor pollicis brevis, abductor pollicisbrevis, and opponens pollicis ) this smallbut important nerve passes over the fexor

pollicis longus tendon and its sheath, Fig-ures 4, 5, and 7. Every surgeon.openingthis sheath in a case of suppurative teno-synovitis must make certain that the prox-imal end of his thumb incision extends no

farther than the midpoint of the ftrst

metacarpal bone, thereby avoiding sec-

tion of the motor nerve to the thenar

eminence muscles (Figure 54).

From the nerves supplying the lateral

aspect of the index finger and adjacent

sides of the second and third ffngers arise

small branches respectively to the first

and second lumbrical muscles.

C I B A

CUTANEOUS BR, OFRADIAL N. TO LAT.THENAR AREA

PALMA,RBR. OF

THENAR

MOTORMEDIANTHENAR

CUTANEOUSMEDIAN N.

MUSCLES

BR.OFN. TOM.

FIGURE I

PALMAR AP(

DIGITAL AR']

SUPERFICIALMETACARPA

CUTANEOUSNERVE TO .

rnd

een

md

rta-

be-

3rs.

lnding

hes

r o f

'pal

lat-

ide

:ral

.woter-

rnd

lju-

3rs.

nce

rlar

om

mb0 2 -b*

l t o

theicis

rall

xorl io--o

ing

no-

ox-no

irstiec-

nar

CUTANEOUS BR. OF \RADIAL N. TO LAT.THENAR AREA

PALMAR CUTANEOUSBR. OF MEDIAN N.

THENAR MUSCLES

MOTOR BR.OFMEDIAN N. TOTHENAR M.

FIGURE I

PALMAR CUTANEOUS BR. OF ULNAR N.

P,A.LMARIS TONGUS TENDON

VOLAR CARPAL LIGAMENT

PISIFORM BONE

ULNAR ARTERY

HYPOTHENAR MUSCLES

PALMAR APONEUROSIS

MINUTE FASCICULI ADHERENT TO DERMA

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PALMAR APONEUROSIS

DIGITAL ARTERIES AND NERVES

SUPERFICIA,L TRANSVERSEMETACARPAL LIGAMENT

CUTANEOUS BRANCH OF ULNA,RNERVE TO 5th FINGER

FIGURE 2 iil,,,r ',4

The ulnar nerDe, shown in Figures 4,

6,7, and 30, passes lateral to the pisiform

bone, and just distally it bifurcates into

superficial and deep rami. The former,

after giving a filament to the unimportant

palmaris brevis muscle, promptly divides

into a branch to the medial aspect of the

fifth finger, a branch supplying contigu-

ous surfaces of the fifth and fourth fingers,

and finally a fine twig which unites with

the most medial branch of the median

nerve (Figure 7 ). The deep ramus of the

ulnar nerve fr-rrnishes muscular branches

to the hypothenar eminence muscles (the

abductor dig. quinti, flexor dig. quinti,

opponens dig. quinti) and to the three

volar and dorsal interosseous muscles, and

the adductor poll icis muscle (Figure 30).

The tiny branches to the third and fourth

lumbrical muscles and the deep head of

the flexor pollicis brevis muscle can be

seen,Lesions of the radial, median, and ulnar

nerves will be discussed after the muscles

have been reviewed.

MUSCLES OF THE I{AND

Muscles of the hand can be grouped as

extrinsic and intrinsic. While the muscle

bellies of the former are in the forearm,

their tendons, nevertheless, are in the

hand and play a very important part in its

movements.Supination of the hand, be it recalled,

is controlled chiefly by the biceps located

in the arm and inserted into the radial

tuberosity, assisted by the supinator mus-

cle originating from the proximal dorso-

lateral aspect of the ulna, wrapping itself

laterally around the proximal fourth of

the radius to insert on its volar aspect. As

previously mentioned, supination is con-

trolled mainiy by the musculocutaneous

n^a a

nerve supplying the powerful biceps and

assisted by the radial nerve supplying the

supinator muscle.

Pronation is controlled by the median

nerve which supplies branches to the pro-nator radii teres and pronator quadratusmuscles found respectively in the proxi-mal half and distal one-fourth of the

forearrn.

Adduction of the hand at the wrist is

produced by the combined action of the

flexor carpi ulnaris and the extensor carpi

ulnaris muscles - the former innervated

by the ulnar nerve and the latter by the

radial nerve. Figure 21 shows the ulnar

flexor tendon on its way to insert into the

pisiform, hamate, and fifth metacarpal

bones. In Figures 17 and 26, the ulnar

extensor tendon is seen proceeding to the

dorsum of the fifth metacarpal bone.

Abduction, like adduction, is efiected

by the combined action of two or more

muscles. To produce abduction, the flexorcarpi radialis contracts synergistically

with the extensors carpi, radialis longus

and brepis. Figure 21 shows the radial

flexor tendon en route to the volar aspectof the base of the second and third meta-

carpal bones. In Figures 17 and 20, the

terminal ends of the two radial extensors

are seen just before they insert into the

proximal dorsal parts of the second and

third metacarpal bones,In addition to producing abduction,

these three muscles have another impor-

tant r6le. Recall that the second and third

metacarpal bones are fixed proximally by

ligaments to each other and to the capi-

tate and lesser multangular bones of the

tran,soerse carpal arch. Distally, they arefirmly anchored to each other by the deep

tr&nsDerse metacarpal ligament. These

strong proximal and distal attachments of

the second and third metacaroal bones

mnkc them the most sl

of the hand.The extensors carpi r,

brcais insert into the do

mel end of the second a

pals; and, v'hile there

carpi ratlialis, it is vc

gains insertion into tht

the proximal ends of thr

metacarpal bones. Withit is easy to see how I

muscles, along with the

ligaments. aid in stabil i:

part of the hand, especr

extension movements o:

In many reconstructthe badly mutilated har

for the surgeon to rem

tant muscle-tendon-bor

nation. Flexion of the h

effected by the flexorsu lna r i s supp l i ed res ;

median and ulnar nerveinates from the mediadvle. the latter from th

plus the proximal three

Extension of the ha

produced by the exlen

longus and breois and

ulnari,s. 'Ihe radial efrom the lateral epiconrof the lateral epicondyJ

ext?trsor from the medmiddle half of the ulna

While the chief func,

muscles are extension

abduction and addur

together with their fel

they are also synergic

of the fingers because t

flexor efiect which t

would otherwise prodrFlexion of the fnge

produced mainly by th

C L I N I C A L S Y M P O SC I B A

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make them the most stable or fixecl partof the hand.

The extensors carpi rndialis /ongrrs andbreois insert into the dorsum of the proxi-mal end of the second and third metacar-

pals; and, rvhile there is only one flexorcarpi radialis, it is very powerful andgains insertion into the volar aspects ofthe proximal ends of the second and thirdmetacarpal bones. With this arrangement,it is easy to see how these three strongmuscles, along with the above-mentionedligaments, aid in stabilizing the most fixed

part of the hand, especially in flexion andextension movements of the fingers.

In many reconstructive procedures ofthe badly mutilated hand, it is imperativefor the surgeon to remember this impor-tant muscle-tendon-bone-ligament combi-nation. Flexion of the hand at the wrist isefiected by the flexors carpi radialis andulnar is suppl ied respect ive ly by themedian and ulnar nerves. The former orig-inates from the medial humeral enicon-dvle. the latter from the same epicondyleplus the proximal three-fifths of the ulna.

Extension of the hand at the wrist isproduced by the extensors carpi radialislongus and breois and the extensor carpiulnaris. The radial extensors originatefrom the lateral epicondyle and distal partof the lateral epicondylar ridge, the ulnarextensor from the medial epicondyle andmiddle half of the ulna.

While the chief functions of these threemuscles are extension of the hand, andabduction and adduction by workingtogether with their fellow carpal flexors,they are also synergic muscles for flexionof the fingers because they counteract theflexor effect which the digital flexorswould otherwise produce at the wrist.

Flexion of the fingers on the hand isproduced mainly by the flexors digitorum

C L I N I C A L S Y M P O S I A

sttblinils and profunclus. The assistantflexor rdle of the lumbrical ancl interosse-ons rnuscles ( flexion of proximal pha-langes) rvili be discussed in the paragraphsdealing with the intrinsic hand muscles.

The flexor cli git orum subllni,s originatesfrom the medial hr,rmeral epicondyle, thecoronoid process of ulna, and the prox-imal two-thirds of the volar rnargin of theratl ius. Proximal to the volar carpal l iga-ment, the muscle gives rise to four ten-dons inserting into the proximal thirds ofthe middle phalanges of the medial fourdigits. The vincula longa and breva giveadditional insertion into.the proximal andmiddle phalanges.

For c l in ica l reasons, the fo l lowingpoints regarding the tendons of this mus-cle deserve to be remembered:1. As is shown on pages 88 and 89, just

proximal and deep to the volar carpalligament, the third and fourth sublimistendons lie superficial to the secondand fifth tendons. This is a quite con-stant arrangement. However, in somecases the third, fourth, and fifth sub-limis tendons will be in the superficialplane with the second or index fingertendon deep to the third sublimis ten-don. Seldom are all four in one planein this region as are the flexor digi-torum profundus tendons.

2. Next, note the manner of insertion ofa sublimis tendon, Figures 5, 24, and34. The sublimis tendon first splits atthe proximal end of the first phalanxto permit passage of the profundus ten-don and then reunites, only to split asecond time to gain insertion on eachside of the proximal third of the sec-ond phalanx.

The flexor digitorum profundus origi-nates from the proximal two-thirds of theulna and the adjacent interosseous mem-

I D

RADIAL A. ANDVENAE COMITES

RADIAL BURSA

ABDUCTOR POLLICIS BREVIS

fruusvrnsrtrr*o* ,orr,.

:"sneAtH orFLEXOR

CARPAL TIG.

IS BREVISHOOK RAISING SKIN TO DEMONSTR,A,TELOOSE ATTACHMENT AND DORSALSUBCUTANEOUS SPACE

RADIAL NERVE (RAMUS SUPERFICIALIS)

CEPHALIC VEIN

POLLtCtSTONGUS

BASILIC VEIN

ULNAR NERVE (RAMUS

DoRSALTS MANUS)

DORSAL VENOUS ARCH

DORSAL DIGITAL NERVES

PROBE IN FIRSTLUMBRICALSHEATH

PALMARAPONEUROSISTURNED DOWN

FIGURE 4

DORSAL BRANCHESOF PROPER VOL,ARDIGITAL NERVES

PROBE IN THENAR SPAOR BURI

PROBE IN DORSAI EXTIOF THENAR SPACE BEIABDUCTOR POLLICIS

CRUCIATE AND ANNUL

INSERTION OF FLEXOR

INSERTION OF FLEXOR

Y r".-,",'1. :i \:.,1, riilt'

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RADIAL A. ,ANDVENAE COMITES

RADIAL BURSA

ABDUCTOR POLLICIS BREVIS-TRANSVERSE

CARPAT LIG.

:LEXOR POLLICIS BREVIS

.SHEATH OFFTEXORPOLLtCtSLONGUS

PROBE IN FIRSTLUMBRICALSHEATH

PALM,ARAPONEUROSISTURNED DOWN

FIGURE 4

ULNAR ARTERY AND VENAE COMITES

ULNAR BURSA

VOLAR CARPAL LIGAMENT

PISIFORM BONEP,ALMARIS LONGUS TENDONULNAR ARTERY ,AND NERVEDEEP DIVISION ULNAR NERVE ,AND ARTERY

SUPERFICI,A,L DIVISION ULNAR NERVE(SENSORY TO 4rh AND 5ih FTNGERS)

MEDTAN NERVE (D|G|TA,L SENSORY BRANCH)

ULNAR BURSA

SUPERFICIAL VOLAR ARTERIAL ANDVENOUS ARCHES

2Nd, 3rd AND 4ih LUMBRICAL MUSCLES

SEPTA

TENDONSHEATH

b';;

PROBE IN THENAR SPACEOR BURSA

PROBE IN DORSAL EXTENSIONOF THENAR SPACE BEHINDABDUCTOR POLLICIS

CRUCI,ATE AND ANNULAR LIGAMENTS

INSERTION OF FLEXOR DIG. SUBLIMIS

INSERTION OF FLEXOR DIG. PROFUNDUS

BRANCH OFMEDIAN N.TO THENARMUSCLES

ABDUCTORDIGIT V

FLEXORDIGIT V

OPPONENSDIGIT V

5th FINGERSHEATH

PROBE INMIDPALMARSPACE ORBURSA

rii'**F IGURE 5

RADIAL ARTERY

MEDIAN NERVESUPERFICIAL BRANCH OF RADIAL ARTERY

ANTERIOR CARPAL ARCH AND RETE

DEEP PALMAR ARTERIAL ,ARCH

SUPERFICIAL PALMAR ARTERIAL ARCH

lst VOLAR METACARPAL ARTERY

ULNARARTERY

ULNARNERVE

PISIFORMBONE

HOOK OFHAMATE

DEEP PALMARDrvrsroNs oF

AND NERVE

: . SUPERFICIALPALMARDIVISION OFULNAR NERVE

COMMUNI .CATIONBETWEENMEDIAN ,ANDULNAR NERVES

F IGURE 6

brane. It inserts into thrthe palmar aspect of theof the medial four di1ofier additional insertior

Figure 24 shows theprofundus as already haits four tendons. Actualhpoint it is not uncommcprofundus tendon to thethe large, distal fibrorthe remainder of the pwhich then divides aboudistad into the tendons trfourth, and fifth fingers.

Extension of the fing,produced by the combi:ertrinsi,c and intrinsic rnt

The extensor muscleand the compartment thrpass at the wrist are shThe chief extrinsic exteris the extensor digitorunextensor indicis propriusproprius assist in extenrthe index and fifth finger

The extensor digitorunnates from the lateral hurintermuscular septa, andcia. It divides into foupass through the fourthment. In this connectiormention that not uncornsor digitorum communitendons passing throughcompartment. The fourtlthe dorsum of the handfinger extensor and goesfifth finger. The extensotalso passes through this

The manner of theertensor digitorum cor,deserves special mention,the deep part of the extcommunis tendon inserti

C L I N I C A L S Y M P o S I T

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PROPER DIGITAL ARTERIESAND NERVES OF THUMB

DISTAT TIMIT OFSUPERFICIATARTERIAT ARCH

ULNAR ARTERY AND NERVE

RADIAL ARTERY

MEDIAN NERVE

PALMAR CUTANEOUS BRSUPERF[CIAL BRANCHOF R,ADdAL ,ARTERYABDI, 'CTOR POIL. , , : , ,BREVIS

OPPONENSPOI-LICIS ,: I

MOTOR BR..-

COMMON VOLAR DIGITAL ARTERIES AND NERVES

VOLAR METACARPAL ARTERIES{

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, b \ t l o o r

PROPER VOLAR DIGITAL fti.i*'ES AND NERVES

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O F M E D | A N " g l ,NERVE TO g"' '

VOLAR CARPAL LIGAMENT

DEEP PALM,AR DIVISIONS OF ULNAR A. AND N.SUPERFICIAL PALM,AR DIVISION OF ULNAR N.TRANSVERSE CARPAL LIGAMENTSUPERFICIAL PALMAR ARTERI,AL ARCHCOMMON VOLAR DIGIT,AL A. AND N.

COMMIJNICATNON EETWEENMEDIA.N AND ULNAR N.

PROPER VOLAR DIGITAL A. AND N.

THENAR $Mu5cLES,,;i

FLEXOR '];]:.

POLLICISI: lBREVIS .; :

PROPER DIGITALA. AND N.OF THUMB

F IGURE 7

brane. It inserts into the proximal half of

the palmar aspect of the terminal phalanxof the medial four digits. The vincula

ofier additional insertion.

Figure 24 shows the flexor digitorum

profundus as already having given rise to

its four tendons. Actually, however, at this

point it is not uncommon to see only the

profundus tendon to the index finger and

the large, distal fibromuscular part ofthe remainder of the profundus muscle,

which then divides about two centimetersdistad into the tendons going to the third,fourth, and fifth fingers.

Extension of the fingers and thumb is

produced by the combined action of theextrinsic and intrinsic muscles.

The extensor muscles, their tendons,

and the compartment through which they

pass at the wrist are shown on page 92.The chief extrinsic extensor of the fingersis the extensor digitorum commttnis. Theextensor indicis proprius and digiti quintiproprius assist in extending respectivelythe index and fifth fingers.

The extensor digi,toru.m communis origi-nates from the lateral humeral epicondyle,intermuscular septa, and antebrachial fas-cia. It divides into four tendons whichpass through the fourth dorsal compart-ment. In this connection, it is worthy ofmention that not uncommonly the exten-sor digitorum communis has only threetendons passing through the fourth dorsalcompartment. The fourth tendon arises onthe dorsum of the hand from the fourthfinger extensor and goes from there to thefifth finger. The extensor indicis propri,usalso passes through this compartment.

The manner of the insertion of theextensor digitorum communis tendonsdeserves special mention. Figure 35 showsthe deep part of the extensor digitorumcommunis tendon inserting into the dor-

C L I N I C A L S Y M P O S I A

sum of the proximal phalanx. This inser-

tion gives purchase to the muscle for the

performance of its chief functions: ( f ) toextend the proximal phalanx to extensionand hyperextension and (2) to stabilizethe proximal finger joints so that the intrin-

sic muscles (lumbricals and interossei)not only can extend the middle and distal

phalanges but are also able to give lateralmovement to the fingers.

As the extensor communis tendon con-tinues distally, it divides into three parts( shown on page 95 ). A central slip inserts

into the dorsum of the proximal end of themiddle phalanx. Two lateral tendinousslips unite with the tendons of the lum-brical and interosseous muscles and con-tinue distally to the proximal end of thedorsum of the terminal phalanx for inser-tion. Despite the insertions of the extensordigitorum communis into the middle andterminal phalanges, th is muscle canextend these two phalanges only veryslightly, if at all, when the proximal pha-langes are in extension. This occurs

because so much of each of the extensor

digitorum communis tendons is insertedinto the dorsum of the proximal phalangesthat when the muscle contracts, most ofits power is concentrated in extending the

proximal phalanges.Furthermore, this firm anchoring of the

tendons to the proximal phalanges per-mits but little extension of the middle andterminal phalanges by the extensor com-

_ munis when the proximal phalanges arein the extended position. The arrows on

page 95 show how the tendons of thelumbr ica l muscles and interosseoLrs

muscles, especially the volar interossei,inserted into the lateral slips of the exten-sor digitorum communis, are able to domost of the extending of the middle andterminal phalanges when the proximal

79

_, _ |

L Y M P H A T I C D R A I N A G E phalanges are extendechanges, however, as sordigitorum communis rrto permit the flexors diand profundus to begin 1and terminal phalangesthis causes the extensor,to be pulled distal to tllangeal joint just enoughlumbricals and interossthen flex the proximal pthe important flexors of 1langes are the lumbricalmuscles.

It seems almost palthese intrinsic musclesphalanges and extend thminal phalanges. But aures on page 95 will rdorsal expansion or "hoo

imally to the metacarpr( this occurs when the e;communis has extendrphalanges), contractiorcals and interossei exrand terminal phalangehand, when the "hood'

to the metacarpophalaroccurs wjth the synergithe extensor digitorumflexion of the digitorumfundus), contraction orand interossei results iproximal phalanges. Ncgers are flexed (for exanthe extensor digitorumIateral slips takes over altrol of the extension ofterminal phalanges; andare three-fourths flexed,torum communis assumthe extension of these pl

The interosseous musinsertion into not only tl

C L I N I C A L S Y M P O S l

DELTO PECTORAL NODE

AXILLARY NODES(ALONG AXtLTARY VEtN)

CEPHALIC VEIN

i

MEDIAN CUBITAL VEIN

BASILIC VEIN

CEPHALIC VEIN

F IGURE 8

EPITROCHLEAR NODES

VESSELSPASSINGTO DORSUMOF HAND

TO

VESSELS FROMCENTER OF PALA\DEEP TYMPHATICS

VESSELSAROUNDDORSUM

PASSINGWEB TOOF HAND

VESSELS PASSINGTO DORSUM OFFINGERS

FIGURE 9

w..phalanges are extended. The situationchanges, however, as soon as the extensordigitorum communis relaxes sufficientlyto permit the flexors digitorum sublimisand profundus to begin flexing the middleand terminal phalanges. Simultaneously,this causes the extensor communis ..hood,,

to be pulled distal to the metacarpopha_Iangeal joint just enough, so that *h"r, thelumbricals and interossei contract. thevthen flex the proximal phalanges. ln fact,the important flexors of the proximal pha_Ianges are the lumbricals urrd irrt"rorrlousmuscles.

It seems almost paradoxical to havethese intrinsic muscles flex the proximalphalanges and extend the middle and ter_minal phalanges. But a study of the fig_ures on page 95 wil l show that if thedorsal expansion or "hood,,is pulled prox_imally to the metacarpophalangeal joint( this occurs when the extensor digitorumcommtrnjs has extencled the nroximalphalanges) , contract ion of the hrmbr i -cals and interossei extends the middleand terminal phalanges. On the otherhand, when the "hood" is pullecl distalto the metacarpophalangeai joint (thisoccllrs with the synergistic relaxation ofthe extensor digitorum communis andfexion of the digitorum sublimis and pro_fundus ), contraction of the lumbrialsand interossei results in flexion of theproximal phalanges. Now when the fin_gers are flexed (for example,45 degrees),the extensor digitorum communis via itsIateral slips takes over about half the con_trol of the extension of the middle andterminal phalanges; and when the fingersare three-fourths flexed, the extensor Jgi-tonrm communis assumes full control inthe extension of these phalanges.

The interosseous muscles gain partialinsertion into not only the lateral aspects

C L I N I C A L S Y M P O S I A

of the proximal ends of the proximal pha_langes but also into the lateral

"rpe"i, of

the capsules of the metacarpophalangealjoints (Figures 33, 34, and 35). It is theseinsertions which enable the ulnar_nerve_controlled interossei to spread and approx_imate the fingers. N4ore will be said of thisin the discussion on the intrinsic musclesof the hand.

Needless to say, it is important to under_stand the synergistic play of extrinsic andintrinsic muscles in the production ofhand and finger movements; and it isequally obvious that it can be unclerstooclonly if one has a clear picture of thedetailed origins, insertioris, and nervesupply of these muscles.

The tendon of the fifth finger propriusmtrsc le (extensor d ig i t i qu inf i ) passesthrorrgh the fifth compartment rrnder thedorsal carpal l igameni, Figrrres 26 and 27.It arises by a thin, tendinous slip from thecommon extensor in the forearm, and itinserts into the dorsal aponeurotic expan_sion hood on the dorsum of the nroximalphalanx of the fi l th f inger. It aids inextending this phalanx ond th" hand atthe wrist.

The tendon of the extensor ind.icis pro_prius passes through the forrrth clorsalcompartment with the three or four exten_sor communis tendons, as the case may be,F igures !6 and 27.The muscle arise, iromthe dorsum of the ulna, near the iunctionof its proximal three-forrrths and distalone-fourth. It assists in extending theproximal phalanx of the index finqe,. andthe hand at the wrist.

Whenever a tendon transplant is neecledfor repair of the very important extensorpollicis longus tendon, the tendon of thepalmaris longus muscle is used. If the lat_ter is absent, the tendon ofthe extensor in-dicis proprius muscle serves the purpose.

IJ

RSUM{D

B1

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DORSALLIGAMENT

B l o o d s u p p l y r e o c h e s l u n o t ebone v iq on ie r io r ond pos-f e r i o r l i g o m e n t s f r o m r o d i u s .

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Ar ter io r d ls locq t ion w i th rup ture \ 1o t cn .e l igomenl . Desp i te impo i red

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b t o o d s u p p l y , e o r l y r e d u c r i o n . o y e i i , E * "p r e v e n l n e c r o s i s

F IGURE

BIFURCATION

COMMON DIGITAL ,A.

VOLAR INTEROSSEOUS A.

Anter io r d is locq f ion w i th rup tureo f b o t h l i g o m e n f s . S i n c e b l o o dsupp ly i s cu t o f f , o voscu lq rnecros is resu l ts .

NAIL

NA|L BED (MATR|X)

PARONYCHIUM

TERMINAL PHALANX

MINUTE ARTERIES

NERVES

SEPT,A,

DORSAL DIGITAL A. AND N.

The thumb is an exupart of the hand. Its metrrue 6, is the most mobilcarpal bones. Attachedits proximal end is the rabductor pollicis longttmay insert by one, two <dinous slips, Figures 2(this strong muscle can gias three tendinous sliprmay have as many as tlgin: the proximal partinterosseous membrane,of the radius. This rnrextends the first metacarthe first metacarpocarpalcould not ftinction witlA stenosing tenosynovbesets this tendon at thpasses through the firstthe radius, Figures 20,condition is also knownclisease. Surgical removthe compartment usuall

The extensor pollicis Iarises from the interosrand dorsum of the radiurabove-mentioned abductand inserts into the dorsmal end of the first phalaIt extends this phalanx aextcnding and abductin5wrist.

The extensor pollicis klarger and more powerfceding muscle, originatestltircl of the dorsum of thosseous membrane and isdorsum of the proximal tnal phalanx of the thurnterminal phalanx, and Ipollicis brevis, on contassists in extending the hThe tendon is quite freq

C L I N I C A L S Y M P O S I I

FIGURE ' I I

ANTERIORLIGAMENT

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I n i w o - t h i r d s o f i n d i v i d u o l s , b l o o ds u p p l y t o s c o p h o i d i s d i s t r i b u t e dt h r o u g h o u t b o n e ( A ) . I n o t h e r s ,v e s s e i s e n f e r o n l y d i s i o l h o l f ( B ) ; i nfhese coses necros is o f p rox imo lhq l f resu l ts q f ie r f roc iu re-

F IGURE I4

BRA,NCHES OF PROPER VOLAR DIGITAL,A. AND N. TO DORSUM OF 2ndAND TERMINAL PHALANGES

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PROPER VOLAR DIGITAL A. AND N.

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F I G U R E I 6

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The tlrumb is an extremely important

part of the hand. Its metacarpal bone, Fig-Lrre 6, is the most mobile of all the meta-carpal bones. Attached to the dorsum ofits proximal end is the surprisingly stoutabductor pollicis longus tendon, whichmay insert by one, two or even three ten-dinous slips, Figures 20 and 26. Just asthis strong muscle can give rise to as manyas three tendinous slips for insertion, itmay have as many as three heads of ori-gin: the proximal part of the ulna, theinterosseous membrane, and middle thirdof the radius. This muscle abducts orextends the first metacarpal and stabilizesthe first metacarpocarpal joint. The thumbcould not function without this muscle,A stenosing tenosynovitis occasionallybesets thrls tendon at the point where itpasses through the first compartment onthe radius, Figures 20, 26, and 27. Thiscondition is also knorvn as de Queraain'sdiseaso. Surgical removal of the roof ofthe compartment usually effects a cure.

The extensor pollicis breais, Figure 20,arises from the interosseous membraneand dorsum of the radius just distal to theabove-mentioned abductor pollicis longusancl inserts into the dorsum of the proxi-mal end of the first phalanx of the thumb.It extends this phalanx and also assists inextending and abducting the hand at thewrist.

The extensor pollicis longus, Figure 20,larger and more powerful than the pre-ceding muscle, originates from the middletlilrcl of the dorsum of the ulna and inter-osseous membrane and is inserted into thedorsum of the proximal end of the termi-nal phalanx of the thumb. It extends theterminal phalanx, and like the extensorpollicis brevis, on continued action, itassists in extending the hand at the wrist.The tendon is quite freqr,rently ruptured

C L I N I C A L S Y M P O S I A

in a severe Colles' fracture; if not at thetime of fracture, it may occur five to sixweeks after the accident.

It should be observed that each of thethree bones associated with the thumb(first metacarpal bone, and proximal anddistal phalanges ) has a tendon of one ofthe above-mentioned mr-rscles insertedinto the dorsum of its proximal end, Fig-ures 7 and 20. The saddle-shaned surfaceof the greater nrrrltangrrlar bone, articrr-lating with the concavo-convex surface ofthe first metacarpal bone, permits a verywide range of movement of the thumbwhen acted upon by the above muscles,as well as the flexor pollicis longus andrelated intrinsic muscles of the hand,Figure 32.

Because lacerations involving tendons,vessels, and nerves about the wrist arequite common, it is important to reviewthe anatomic re lat ionships of thesestructures.

ARRANGEMENT OF

TENDONS) VESSELS, AND NERVES

AT THE WRIST

Figures 21 and 23 show schematicallythe general arrangement of the tendons,vessels, and nerves under the volar carpalligament. By clenching the fist tightly andflexing the wrist as though against resist-ance, one can usually palpate the palmarislongus tendon (absent in 10 per cent ofhands), the flexors carpi radialis andulnaris tendons, and the superficial ten-dons of the flexor digitorum sublimis.

Next palpate the median duo, consist-ing of the palmaris longus tendon ( super-ficial to the volar carpal ligament) andmedian nerDe, the latter being deep andslightly lateral to the tendon.

Palpation of the radial pulse reminds

@%

ffi83

MEDIAT ANTEBRACHIALCUTANEOUS NERVE

DORSAL ANTEBRACHIALCUTANEOUS BRANCHOF RADIAL NERVE

ULNAR NERVE-DORSAL BRANCH(RAMUS DORSALTS MANUS)

DORSAL CARPAL BRANCHOF ULNAR ARTERY

TENDON OF EXT. CARPI ULNARIS

DORSAL CARPAL ARTERIALARCH AND RETE

DORSAL MET,ACARPAL ARTERIES

DORSAL DIGIT,AL ARTERIES

DORSAL DIGITAL BRANCHESOF ULNAR NERVE

AREAS OF SKIN INNERVATIONOF HAND

DORSUM

LATERAL ANTEBRACHIAL CUTANEOUSBRANCH OF MUSCULOCUTANEOUS N,

RADIAL NERVE-SUPERFICIAL BRANCH

DORSAL CARPAL LIGAMENT

RADIAL ARTERY (IN "SNUFFBOX")

TENDON EXT. CARPI RAD. LONGUS

TENDON EXT. CARPI RAD. BREVIS

TENDON EXT, POLL. LONGUS

DORSAL DIGITAL BRANCHESOF RADIAL NERVE

FIGURE I7

T, j,ri,*i::n" '

" . ' "" @cIBA

PROPER VOLAR (PALMAR) DrGrT,A,rBR,ANCHES OF MEDIAN NERVE

F IGURE I9

MEDIANNERVE(PROPER VOLARDIG. BRANCHES)

tg

EXT.CARPIRADIALIS ,,sBevs,/LOt IOUS /

I st DORSAI.INTEROSSE(MUSCLE

ADDUCTOR(SEEN THRU

N .CUT. BR .

F IGURE I8

1

EXT.CARPIRADIALISBREVIS,LONGUS

I st DORSALINTEROSSEOUSMUSCLE

A D D U C T O R P O L L I C I S(SEEN THRU FASCIA)

SUPERFICIAL RAMUS OF RADIAL NERVE

DORSAL CARPAL LIGAMENT

STYLOID PROCESS OF RADIUS

SCAPHOtD (NAVICULAR) BONE

R.ADTAL ARTERY ( lN "SNUFFBoX")

INSERTION OF ,ABDUCTORPOLLICIS LONGUS

INSERTIONOF EXTENSORBREVISPOLL IC IS

INSERTION OFEXTENSCR POLLICIS

LONGUS

F IGURE 20

t-

one of the radial trio, consisting of theradial artery, and ulnarward from it, theradial flexor (fexor carpi radialis), anddeep and ulnarward of this stout tendon,the flexor poUicis longus tendon. With thefist tightly clenched and the wrist flexed,one has little difficulty in palpating accu-rately with one's thumbnail the sharp-bordered ulnar fl.exor tendon (fexor carpiulnaris ). If the ball of the thumb is usedfor palpation, it not only presses upon theulnar flexor but also upon the superficialtendons of the flexor digitorum sublimis.

Palpation of the sharp-bordered ulnarflexor tendon brings to mind the ulnar triowhich consists of the ulnar fl.exor tendon,the laterally placed ulnar nerae, and theadjacent ulnar artery. Again, with fistclenched and wrist fexed, one is remindedthat the two digital flexor tendon quartetsare medial to the centrally located pal-maris longus tendon. Figure 23 showsschematically the relationship of the sub-limis tendons. Those acting on the thirdand fourth fingers are superficial to thoseof the second and fifth fingers. This ismost easily remembered by piacing one'ssecond and fifth fingers behind the thirdand fourth fingers as in Figure 22 andhav-ing in mind that 34 is a higher numberthan 25. Not uncommonly, sublimis ten-dons to the third, fourth, and fifth fingersare in the superficial plane, and the indexfinger sublimis tendon is deep to the thirdsublimis tendon.

Figure 23 shows the four flexor digi-torum profundus tendons lying in oneplane which is deep to the sublimis ten-dons. As previously mentioned, it is notuncommon to find at this point onlv theprofundus tendon to the index firrg"r r"pu-rated from the distal fibromuscular endof the flexor digitorum profundus - theother three tendons arising one to two

86

centimeters distad. A, subtendinous space(Parona) exists between all the abovestructures and the slluare pronator mus-cle (pronator quadratus). In discussinghand infections, this space will again bementioned.

By insular attachments on the dorsalandlateral aspects of the radius and ulna,the dorsal carpal ligament creates six com-partments for the passage of extensor andabductor tendons to the hand and fingers.Figure 26 shows the three thumb tendonsbounding the anatomical snuffbor; theabductor pollicis longus and extensor pol-l icis breuis on the volar'boundary, andthe extensor pollicis longus on the dorsalboundary.

The first two tendons of the snufibox(abductor pollicis longus and extensorpollicis breois) are in the first compart-ment, and the third tendon of the snuffbox(extensor pollicis longus) is in the thirdcompartment. Thetuo radisl extensor ten-dons (ertensors carpi radialis longus andbreois) are in the second compartment.

One can associate the four communistendons with the fourth compartment;and, as one wag expressed it, the extensorindicis propri.us tendon is a "fellow-trav-

eler" accompanying these four tendons.As previously mentioned, the extensordig i torum communis may g ive r isedirectly to only three tendons, in whichcase the extenaor indicis proprius tendonwill be the fourth tendon. The tendinousslip to the fifth finger from the extensordigi,torum communis will then branch ofifrom the tendon going to the fourth finger.

The extensor digiti quinti proprius fitswell into the fffthcompartment.The ulnerertensor tendon (extensor carpi ulnaris)falls easily into the ulnar, or sixth com-partment.

Figures 20 and 26 show the anatomical

Because the first dorsal incle gives no notable tendtion to the lateral tendinfirst lumbrical muscle, itpractically no aid in the rmiddle and terminal phindex finger. Their ertenby the first lumbrical rnvolar interosseous musclrnous slips insert into themiddle and proximal pha

The second and tltird aous muscles insert respertubercles on the radial anthe proximal phalanx of tland into the lateral sliprexpansion hood which exthe middle and terminalinsertion. When the tendrsor digitorum communis e:imal phalanx of the th jsecond and third dorsal incles can extend the middphalanges via the lateralwag" the middle finger.respectively radialward rbecause of their insertionmal phalanx. The arrows c95 depict these movemrtendon of the extensor (

rrurnis to the third fingetraction of the second arinterosseous muscles causrproximal phalanx.

The fourtl't dorsal interinserts into the ulnar side

phalanx of the fourth fingeof the joint capsule, and tlthe dorsal expansion. Witphalanx extended, the fourosseous muscle will pull tlaway from the third fin1extending tlae middle andlanges via its attachmenl

C L I N I C A L S Y M P O S I A

a

C I B A

ad. A subtendinous spacebetween all the above

ihe square pronator mus-

ruadratus). In discussing

, this space will again be

.tachments on the dorsalcfs of the radius and ulna,I ligament creates six com-re passage of extensor andrs to the hand and fingers.; the three thumb tendonsTnatomical snuffbox: thes longus and extensor pol-the volar boundary, and',Iicis longus on the dorsal

tendons of the snuffboxcis longus and extensorare in the first compart-ird tendon of the snuffboxis longus) is in the thirdhetuo radi,al extensor ten-carpi raclialis longus andhe second compartment.ciate the four communishe fourth compartment;expressed it, the extensor

tenclon is a "fellow-trav-

ying these four tendons.mentioned, the extensor,Lmunis may g ive r ise

three tendons, in which,r indicis proprius tendonth tendon. The tenclinousfinger from the exten,sorrurzis will then branch ofigoing to the fourth finger.digiti quinti proprius frtsh compartme nt. The ulnar. (extensor carpi ulnaris)the ulnar, or sixth com-

il 26 show the anatomical

snuffbox and its important contents. The

tip of the styloid process of the radius can

be felt at its proximal end. A small part of

the extensors carpi radialis longus and

brevis tendons can be seen, as rvell as the

radial artery. Deep to the radial artery

is the capsule of the wrist joint and

navicular (scaphoid) bone. Because the

navicular bone (Figure 13 ) is the most

frequently fractured carpal bone, it is

clinically more important than the greatermultangular bone - a small part of which

also lies in the snuffbor. F igure 3 shows

sensory branches of the radial neroe,

which are found in the snufJbor. Aware-ness of their presence prompts the sur-

geon to preserve them in surgical proce-dures in this area.

INTRINSIC N,IUSCLES OF THE ILA.ND

These may be grouped into those form-ing the hypothenar eminence, the thenar

eminence, and a third group - the mus-

cles between these two eminences, Fig-

ures 2, 5, 30, 31, and 32.

Muscles of Hypothenar Eminence

'Ihe abductor digiti quinti, the flexordigiti quinti, breois and the opponens

digiti quinti comprise this group, Figures

I, 5, and 21. The abductor digiti quinti

originates chiefly from the pisiform bone

and pisohamate ligament and inserts into

the joint capsule of the fifth metacarpo-

phalangeal joint, the ulnar side of the base

of the proximal phalanx of the fifth finger,

and the ulnar border of the aponeurosis of

the extensor digiti qtLinti proprius. It is

supplied by the ulnar nerve, abducts the

fifth finger when its proximal phalanx is

extended, and flexes the proximal phalanxlvhen the long extensor is relaxed.

The flexor digiti qu,inti breuis arises

C L I N I C A L S Y N I P O S I A

from the hamate bone and transverse car-

pal ligament and is inserted into the ulnar

side of the base of the first phalanx. It is

innervated by the ulnar nerve and assists

in abducting the fifth finger and in flexing

the proximal phalanx.The opponens digiti quinti originates

from the hamate bone and transverse

metacarpal ligament. It is inserted into

the ulnar border of the fifth metacarpal

bone and innervated by the ulnar nerve.

It lies deep to the other two muscles, next

to the fifth metacarpal bone.

The fifth is the second most mobile of

all the metacarpal bones, being movable

about 15 degrees palmarward and dorsal-

ward, Figure 32. Because of this mobility,

the opponens digiti quinti is able to draw

the fifth metacarpal forrvzrrd, thereby

helping to deepen the hollow of the palm.The unimportant palmaris brevis merely

corrugates the skin on the ulnar side of

the palm.

Nluscles of Thenar Eminence

This grotrp consists of the abductor pol-

Iicis breuis, the flexor pollicis breuis, and

opponens poll icis muscles, Figures L, 4,7,

21, and 30. These muscles, which are func-

tionally much more important than those

of the hypothenar eminence, are supplied

almost entirely by the median nerve.

The abductor pollicis breois muscle

originates from the transverse carpal liga-

ment and from the navicular and greater

multangular bones. It inserts into the

radial side of the proximal phalanx of the

thurnb and into the capsule of the meta-

carpophalangeal joint. It aids in abduct-

ing the thumb away from the palm.

The opponens pollicis muscle originates

from the transverse carpal ligament and

greater multangular bone. It inserts into

the whole radial side of the first metacar-

C I B A 87

MEDIANDUO

RADIAL

TRIO

f eaL,ulnrs LoNGUsL

MEDIAN NERVE -\

RADIAL ART.FLEX. CARP. RAD.

FLEX. POLL. LONG

FLEX. CARP. RAD

RADIAL ART.

FLEX. cARp. uLNARrs IULNAR NERVE i ULNARULNAR ARTERy I TRlo

PROFU}

SHEATH OFPOLLICIS LC

PRoBE IN THENAR sPAcE -

LUMBRICAL MUSCLESAND TURNED DOWN

DORSAL SUBCUTANEOUS SPA,

DORSAL -SUBAPONEUROTICSPACE

HYPOTHEN,A,RMUSCLES

MID-PALMARSPACEOR BURSA

FIGURE 25

FLEXOR TENDONSIN SHEATHS

LUMBRICAL MUSCLESIN SHEATHS

VOLAR CARPAL LIG.TURNED BACK

TRANSVERSE CARPAL LIG.

OPPONENS POLLICIS

ABD. POLL.BREVIS

ADDUCTOR POLLICIS

FLEX. POLI . LONG.IN RADI,AL BURSA

MEDTAN f raL,ulnrs LoNGUSDUO

\ ueoAN NERVE\

F IGURE 2 I

ABDUCTOR DIGITI QUINTIFLEXOR DIGITI QUINTI

OPPONENS DIGITI QUINTI

SUPERFICIAL PALMAR ARTERIA|.

,4 { , , r ', f , U t , . , , { e ,

t ,

/ / '

LUMBRICAL MUSCLES

VOLAR CARPAL LIGAMENT

UtNA

{

ARCH il

RADIAL

TRIO

RADIUS

SIMPLE METHOD OF DEMONSTRATINGARRANGEMENT OF SUBLIMIS TENDONSAT WRIST.

F IGURE 22

(-

oF FLEX. I.rmrs A,ND lrwo rrNooNUS IN ULNAR I QUARTETS

I

PRONATOR QUADRATUS

DIVIDED TRANSVERSECARPAL LIGAMENT

RADIAL BURSA

uLNnnrs I'/E ) ULNAR

:RY J TRlo

I DIGITI QUINTI

GITI QUINTI

S DIGITI QUINTI

\L PALMAR ARTERIAL A,RCH

IICAL MUSCLES

FIGURE 23

RONATOR QUADRATUS

PROFUNDUS TENDONS

SHEATH OF FLEXORPOLLICIS LONGUS

PROBE IN THEN,AR SPACE

LUMBRICAL MUSCLES DIVIDED,AND TURNED DOWN

FIGURE 24

tt

w

DORSAL SUBCUTANEOUS SPACE

DORSAL SUBAPONEUROTIC

PROBE INMIDPALMAR SPACE

': .

. @ C I B A

LIGAMENT

fiA,.?-?l; )Ul_;,t*-

Nan anrrnv I

NAR NERVE I uLNnn

. rLrx. crne. I TRlo ]

ULNARTS )

SPACE

HYPOTHENARMUSCLES

,tii#

ADDUCTOR POLLICIS MUSCLE

THENAR SPACE OR BURSA

EXTENSOR POLL IC ISLONGUS TENDON

FLEXOR POLLICIS LONGUSTENDON IN SHEATH

FLEXOR TENDONSIN SHEATHS

LUMBRIC,A.L MUSCLESIN SHEATHS

SEPTA FORMING CANALS

DIGITAL A. AND N. PALMAR APONEUROSIS

pal bone and because of this is largely

responsib le for the movement which

enables the thumb to be approximated

successively to the tips of each of the

fingers. This is recognized as the thumb-

finger -appr oximator test, fr equently used

to test the motor function of the median

nerve.The flexor pollicis breai,s muscle con-

sists of two parts: (L) a superfici,al por-tion, innervated by the median nerve,

originating from the transverse carpal

ligament and greater multangular bone

and inserting into the radial side of the

proximal phalanx and (2) a deeTt and

very small portion, innervated by the

ulnar nerve, arising from the ulnar side

of the first metacarpal and inserting into

the ulnar side of the proximal end of the

first phalanx.All the hypothenar and thenar emi-

nence muscles, except the abductor digiti

quinti, get part of their origin from the

transverse carpal ligament - a purchasewhich enables them (abductor excepted)

to help preserve the carpal arch.

INTEROSSEOUS I{USCLES

There are seven interosseous muscles:

four interossei in the dorsal group and

three interossei in the volar group, Fig-

ures 31 and 32.The four dorsal i,nterosseous muscles

are bipennate rvith their mus.cular heads

of origin from adjacent sides of the meta-

carpal bones. From the figures on pages

92 and 94, one can see how the tendon

of one head of the muscle inserts into the

tubercle on the lateral aspect of the proxi-

mal phalanx or the capsule of the meta-

carpophalangeal jo int , or in to both

tubercle and joint capsule. The other

head inserts into the dorsal expansion and

90

its volar border - the lateral band which

continues distally to the dorsum of the

proximal end of the terminal phalanx. It

is not uncommon for the tendinous slip to

the capsule to arise from the tendon join-

ing the lateral band instead of the one

going to the tubercle.Because the tendon of one of these two-

headed or bipennate dorsal interosseous

muscles has a stout insertion into the lat-

eral aspect of the proximal end of the

proximal phalanx (and this insertion is

slightly more volar than dorsal ) and

because it fuses with the transverse fibers

of the hood, contraction of the muscle

belly associated with this tendon will

cause lateral motion of the proximal pha-

lanx. When the extensor digitorum com-

rnunis relaxes, fexion of this same phalanxoccurs.

Because the tendon of the other belly

blends with the lateral band of the dorsal

expansion (hood ) which continues dis-

tally to the dorsum of the middle and

terminal phalanges, contraction of its

associated muscle fibers will aid in extend-

ing the middle and terminal phalanges(Figures 33,34) .

It is to be noted, however, that the frsfdorsal interosseous is different from the

second, third, and fourth in that it has its

second metacarpal head inserting into the

lateral tubercle of the proximal phalanx

and its first metacarpal head inserting into

the dorsal expansion hood with no contri-

bution to the lateral band slip of the first

lumbrical muscle.This difierent mode of insertion enables

the second metacarpal component of the

first dorsal interosseous to be more efiec-

tive in flexing the proximal phalanx, and

the first metacarpal belly to be the more

important in lateral motion, especially so

in the pinching gesture with the thumb.

Because the first dorsalcle gives no notable tertion to the lateral tendfirst hrmbrical muscle, rpractically no aid in thrmiddle and terminal 1index finger. Their erteby the first lumbricalvolar interosseous mus(nous slips insert into ttmiddle and proximal pl

'fhe second and third

ous muscles insert resptubercles on the radial ithe proximal phalanx ofand into the lateral sliexpansion hood which ethe middle and termin,insertion. When the ten<sor tl igi to r r t m c ont mu nisimal phalanx of the t lsecond and third dorsal icles can extend the mid,phalanges via the laterawag" the middle fingerespectively radialwardbecalrse of their insertio:mal phalanx. The arrows95 depict these moventendon of the extensnrmunis to the third fingtraction of the second zinterosseous muscles caurproximal phalanx.

The fourth, dorsal inteinserts into the ulnar sidephalanx of the fourth fingrof the joint capsule, and Ithe dorsal expansion. Wiphalanx extended, the fouosseous muscle will pull taway from the third finextending the middle anrlanges via its attachmer

C L I N I C A L S Y T { P O S I AC I B A

tIateral band which

the dorsum of the

srminal phalanx. It

he tendinous sliP to

om the tendon join-

instead of the one

of one of these two-

dorsal interosseous

rsertion into the lat-

roximal end of the

.nd this insertion is

than dorsal) and

the transverse fibers

ction of the muscle

rh this tendon will

of the proximal Pha-nsor digi,torum conT'

r of this same Phalanx

rn of the other be1lY

ral band of the dorsal

which continues dis-

r of the middle and

i, contraction of its

rers will aid in extend-

d terminal Phalanges

however, that the frsf

is different from the

iourth in that it has its

head inserting into the

the proximal Phalanxrpal head inserting into

m hood with no contri-

al band sIiP of the first

rde of insertion enables

rpal component of the

seous to be more effec-

proximal Phalanx, and

al belly to be the more

al motion, esPeciallY so

esture with the thumb'

Because the first dorsal interosseous mus-cle gives no notable tendinous contribu-tion to the lateral tendinous slip of thefirst lumbrical muscle, it obviously givespractically no aid in the extension of themiddle and terminal phalanges of theindex finger. Their extension is effectedby the first lumbrical muscle and firstvolar interosseous muscle whose tendi-nous slips insert into the dorsum of themiddle and proximal phalanges.

The second and third dorsal interosse-ous muscles insert respectively into thetubercles on the radial and ulnar side ofthe proximal phalanx of the middle fingerand into the lateral slips of the dorsalexpansion hood which extend distally tothe middle and terminal phalanges forinsertion. When the tendon of the exten-sor digitorum communis extends the prox-imal phalanx of the th i rd f inger , thesecond and third dorsal interosseous mus-cles can extend the middle and terminalphalanges via the lateral slips and "wig-

wag" the middle ffnger, i.e., move itrespectively radialward and ulnarwardbecause of their insertion into the proxi-mal phalanx. The arrows on pages 94 and95 depict these movements. With thetendon of the extensor digitorum com-munis to the third finger relaxed, con-traction of the second and third dorsalinterosseous muscles causes flexion of theproximal phalanx.

The fourtl'r clorsal interosseous muscleinserts into the ulnar side of the proximalphalanx of the fourth finger, the ulnar sideof the joint capsule, and the ulnar side ofthe dorsal expansion. With the proximalphalanx extended, the fourth dorsal inter-osseous muscle will pull the fourth fingeraway from the third finger and aid inextending tlae middle and terminal pha-langes via its attachment to the hood,

C L I N I C A L S Y I { P O S I A

Figure 34. When the extensor tendon isrelaxed, the fourth dorsal interosseousmuscle flexes the proximal phalanx of thefourth finger, Figure 35.

Volar or palmar interosseous musclesare three in number. The first arises fromthe ulnar side of the volar asnect of thesecond metacarpal bone and is insertedinto the same side of the proximal end ofthe first phalanx and lateral band of thedorsal expansion hood of the index finger.The second and third arise respectivelyfrom the radial side of the fourth and fifthmetacarpal bones and are inserted intothe same side of the proximal phalanx ofthe fourth and fifth fingers and lateralbands of their dorsal expansion.

The red arrows in Figure 32 show howcontraction of these muscles results inapproximating the second, fourth, andfifth fingers toward the middle finger. Redarows on page 95 demonstrate how ten-dinous slips given to the lateral bands ofthe dorsal expansions enable these mus-cles to assist in extending the middle andterminal phalanges when the proximalphalanges are extencled by the extensordigitorum communis muscle.

Some prefer including the two-headedadductor pollicis muscle, Figure 30, withthe "median-nerve-controlled" thenar emi-nence muscle group. However, because itis functionally under the control of theulnar nerve as are the seven interossei andthe two lumbrical muscles on the ulnarside of the hand, it seems more logicalto include it with the latter group. Theoblique head of the adductor pollicismuscle arises chiefy from the capitatebone and the bases of the second andthird metacarpals. 'Ihe

transoerse partarises from the distal two-thirds of thevolar aspect of the third metacarpal bone.All of the transverse head and most of the

C I B A91

EXTENSOR CARPI \ULN,ARIS \

THROUGHCOMPARTMENT

J

EXTENS.R poLlrcrs LoNGUs ) .ollJooJ#*,t 3

oblique head insert intothe base of the proximithumb. A sesamoid bormonly found in this tenfibers from the obliqueh,pollicis brevis to insert irof the thumb's first phallocated a sesamoid bonrthe flexor pollicis longustwo points of insertion.

As the name implies, tladductor pollicis musclethe first metacarpal tcmetacarpal bone. Notebetween the action olpollicis, of the "medianthenar eminence group apollicis mascle supplie<nerve: The opytonens pothumb in an arcfu:ing ma

THROUGHCOMPARTMENT

6

FOUR COMMUNISTENDONS PLUSONE FELLOWTRAVELLER IN4th COMPART.

EXTENSOR DIGITIQUINTI PROPRIUS

THROUGHCOMPARTMENT

4

FOUR TENDONS OFEXTENSOR DIGITORUMCOMMUNIS PLUS EXTENSORINDICIS PROPRIUS(FETLOW TRAVETLER)

ABDUCTOR DIGITI QUINTI

TRANSVERSE FIBERS OFDORSAL EXPANSIONS (HOODS)

u(i.t: Jt l t. ' /@ctBA

, 3rd SNUFFBOXEXT. POLL. LONG. } TENDON IN

, 3rd COMpART.

RADtAt ARTERY (tN "SNUFFBOX.)

FIGURE 26

DORSAL INTEROSSEI

I rxr. oro.1 PLUS EXT.I PROPRTUS

COMMUNISrNDtcts

ULNAR 6 EXT. POLL. BR. I t$ AND 2nd

"l \ SNUFFBOXI ABD TENDONS IN* POLL. LONG.J lsr COMPART.

FIGURE 2I

EXTENSOR f rxr. clnprlN 6th I uLNeRrSCOMPART.

UI.NA RADIUSF IGURE 27

l

I THROUGH{GUS i coMpAxTMENT

Als BREVT5 I rxnoucttrs toNGUs I

coMPAxrMENr

crs LoNGUS I rxnoucxtcts BREVIS I

CoMPARTMENT

ARTERY (rN "SNUFFBOX")

oblique head insert into the ulnar side ofthe base of the proximal phalanx of thethumb. A sesamoid bone is not uncom-monly found in this tendon. Some of thefibers from the oblique head join the flexorpollicis brevis to insert into the radial sideof the thumb's first phalanx. Here also islocated a sesamoid bone. The tendon ofthe flexor pollicis longus is between thesetwo points of insertion.

As the name implies,the function of theaclductor pollicis muscle is adduction ofthe first metacarpal toward the thirdmetacarpal bone. Note the difference,between the action of the opponens t

polli.cis, of the "median-nerve-supplied"

thenar eminence group and the adductorpollicis muscle supplied by the ulnarnerve: The opponens pollicis swings thethumb in an arching manner toward the

tips of the fingers, whereas the adductorpoll icis slides or scrapes the thumb acrossthe palm and bases of the fingers towardthe ulnar side of the hand.

With a functionless adductor pollicis,as in ulnar nerve paralysis, it is impossibleto make a perfect "O" with the thumb andindex ffnger or execute the pinch-move-ment between these digits.

In ulnar nerae paralysis, there is notonly a "hollowing-out" due to atrophy ofthe interosseous muscle bulges on the dor-sum of the hand, but there is a noticeablethinning of the thumb-index finger web-

' area due to atrophy of the adductor pollicismuscle. As stated previously, the ulnarneroe can be called the"finger-spreader-

approxi.mator-neroe" because spreading

and approximating the fingers by the dor-

sal and volar interossei, respectively, tests

. FIGURE 26tuORSAL INTEROSSEI

-u,',;i,V,t"'

JRE 27

RADIAL BURSA

ULNAR BURSA

INTERMEDIATEBURSA

THENARSPACE

OR BURSA

MIDPSPACEOR

, 3rd SNUFFBOX. I T E N D O N r N

' 3rd COMPART.

r 2 RADIALAD. BREV. I rxrrNsons,D. LONG. I rN Zna

/ COMPART.

.1. BR. I Isr AND 2ndI sNurrsox/rrNooNs rN

roNG.J rsr GoMPART.)tt.

LUMBRICALMUSCLESIN SHEATHS

TENDONSHEATHS

i 1 ril,,,ilt'i;f

l , , t ' O c t m

FIGURE 29

r-FIGURE 28

l

I_j

RADIAL ARTERY

VOLAR CARPAL BRANCH RAD. A.

RADIUS

SUPERFICIAL BRANCH RAD. A.

HOOK HOLDING BACKTRANSVERSE CARPAL LIG.

OPPONENS POLLICIS M.

MEDIAN N. BRANCHESTO THENAR MUSCLESAND 'I AND 2LUMBRICALS

ABD. POLL. BR.

FLEX. POLL. BR.

ADDUCTORPOLLtCTS

BRANCHESDEEP DIV.ULN. N. TOINTEROSS. M.AND 3 AND 4LUMBRICALS

TUMBRICALMUSCLES TURNEDDOWN

ULNA

LUNATE

TRIQUETRAL

PISIFORM

HAMATE

ABDUCTORDIGITIQUINTIMUSCLE

RADIUS

NAVTCUTAR (SCAPHOtD)

LUNATEGR. MULTANGULAR

LESS. MUTTANGULAR

EXT.

PRONATOR QUADRATUS M.

ULNAR N. (F|NGER-SPREADER N.)

ULNAR ARTERY

CARPAL BRANCH ULNAR A.

TENDON FLEX. CARP. ULNARTS

PISIFORM BONE

VOLAR CARPAT RETE

ABDUCTOR DIGITI QUINTI M.

DEEP PALMAR BRANCH ULNAR A.AND DEEP DIVISION ULNAR N,

FLEXOR DIG. QUINTI BREV. M.

OPPONENS DIGITI QUINTI M.

METACARPAL ARTERIES

COMMON VOL, DIG. ARTERIES

DEEP TRANS. METACARP. LIG.

UtNA

TRIQUETRAT

PISIFORM

HAMATE

CAPITATE

VOLARINTEROSSEI

EXTENSORINSERTION TODISTAL PHALANX

COLLATERALLIGAMENTS

F I G U R E 3 5

INSERTION OF DEEP P(EXTENSOR TENDON TO

ATTACHMENT OFINTEROSSEOUS M. TO

-

BASE OF lst PHALANXAND JOINT CAPSUI-E

TRIANGUIILIGAMEN'

@EXTENSOR INSERTIONTO DISTAL PHALANX

EXIN2n

V

F I G U R E 3 0

VINCBREV

ABD. {RADIUS

LISTER'STUBERCLE

NAVICULARGR. MULT.

LESS. MULT.

CAPITATE

ABD. POLL. BR,

DORSALINTEROSSEI

DEEPTRANS.METACARP.LIG.

TENDINOUSSLIPS TO,HOOD'

VOLAR ASPECT

F IGURE 32

<-*

"9.:1r" ,

' a ; ' b " , " o )

. F , r 't'1fa"r"o

lsi LUMBRIC,AI TEND.

TEND. VOL. INTEROSSEI

F IGURE 33

F IGURE 34

DORSAL ASPECT

F IGURE 33

t

IOR QUADRATUS M.

N. (FTNGER-SPREADER N.)

ARTERY

CARPAL BRANCH ULNAR A.

.I FLEX. CARP. ULNARIS

M BONE

CARPAL RETE

OR DIGITI QUINTI M.

\LMAR BRANCH ULNAR A.iEP DIVISION ULNAR N.

DIG. QUINTI BREV. M.

ENS DIGITI QUINTI M.

METACARPAL ARTERIES

)N VOL. DIG. ARTERIES

RANS. METACARP. LIG.

ULNA

TRIQUETRAI

PISIFORM

HAMATE

CAPITATE

VOLARINTEROSSEI

TRIANGULARI-IGAMENT

SLIPS OF LONG EXT.TO LATERAL BANDS

INTEROSSEOUS

EXTENSORINSERTION TO2nd PHALANX

LATERALBANDS

DORSAT EXPANSTON (HOOD)

METACARPALBONE

INTEROSSEOUSMUSCTE

LONGEXTENSORTENDON

INTEROSSEOUSMUSCTE

LONGEXTENSORTENDON

INTEROSSEOUSMUSCLE

LUMBRICALMUSCLE

INTEROSSEOUSMUSCLE

EXTENSOR INSERTIONTO DISTAL PHALANX

EXTENSORINSERTION TODISTAL PHALANX

COLLATERALLIGAMENTS

F I G U R E 3 5

SLIP TO LAT. BAND

PORTION OF INTEROSSEOUS TENDON PASSING TOBASE OF lsr PHALANX AND JOINT CAPSULE

DORSAL EXPANSION (HOOD)

VINCULABREVA

VINCULALONGA

EXTENSORINSERTION TO2nd PHALANX

'2.LATERAL BAND

+

PROFUNDUSTENDON

FLEX. DIG. SUBLIMISTENDON (CUT OFF)

COLLATERALLIGAMENTS

METACARPAL BONE

SUBLIMISTENDON

DEEPTRANS.METACARP.LIG,

INSERTION OF DEEP PORTION OFEXTENSOR TENDON TO I st PI-IALANX

ATTACHMENT OFINTEROSSEOUS M. TOBASE OF lst PHALANXAND JOINT CAPSI.. jLE

Blqck ArrowsIndicote Pullof Long Extensor;Red Arrowslndicote Pullof Interosseiond Lumbricols

TENDINOUSSLIPS TO"HOOD'

[ -UMBRICAL MUSCLE

CORRECT POSITION FORSPLINTING "MALLETFINGER," NOTE RELAXEDLATERAL BAND

)LAR ASPECT

F IGURE 32

FLEX. DIG.PROFUNDUSTENDON(cur oFF)

F IGURE 36

TENDONENDS

APPROXIMATED

F IGURE 34

^ o$ -qfi*i=.

.l};$''fu,'r @clB.q,

quite efiectively the motor integrity of theulnar nerve.

LUMBRICAL MUSCLES

On the radial side of the palmar portionof each flexor digitorum profundus ten-don is a lumbricalis (worm-like ) muscle,page 77. The first and second lumbricalsoriginate respectively from the radial sideof the first and second fexor nrofundustendons, the thir-d Iumbrical orjqjnatesfrom the adjacent sides of the second anclthird profundus tendons, and the fourthfrom adjacent sides of the third trnd fourthprofundus tendons (Figure 2l). Figures34 and 35 show how these muscles sendtransverse fibrous elements to the dorsalexpansion hood, and a substantial tendi-nous slip to fuse with a similar contribu-tion from the interosseous muscles to formthe lateral bands inserting into the middleand terminal phalanges.

This insertion enables these musclesto flex the proximal phaltrnges when theextensor d ig i tomm longus muscle isrelaxed; ancl the middle and terminalphalangeal inser t ions enable them toextentl these phalanges when the extensordigitorurn longus is extending the proxi-mal phalanges.

The first ancl second or lateral two lum-bricals arising from the first and secondflexor profundus tendons are innervatedby the median nerDe, the third and fourthor medial hvo by the ulnar neroe. This isquite logical when one recalls that in theforearm the lateral half of the flexor disi-torrrm profrrndus. from which arise thetendons to the first and second fingers, isinnervated by the median nerve; themedial half, from which originate the ten-dons to the third and fourth fingers, issupplied by the ulnar nerve.

96

THE EFFECT ON TI{E HAND OF RADIAL,

MEDIAN, AND ULNAR NERVE LESIONS

Seoerance of Radial Nerae

Because of the frequency of arm injuriessuch as shoulder dislocations and frac-tures of the surgical neck and middlethird of the humerus, the radial is themost frequently injured of these threeimportant nerves.

Sensory examination will reveal hvpes-thesia in an area along the dorsum of theforearm about half the width indicated inFigure 19 and also on the hand in mostof the area cliagrammed in Figures 18 and19. There is usually anesthesia of theskin overlying the first dorsal interosseousmuscle.

hlotor examination reveals the tvpical"wrist drop" position of the hand. Theadducted position of the thtimb and theposition of the alreadv flexed hand makesflexion of the fingers somervhat difficult.The hand cannot be extended at the wrist,and the lateral moverlents of the handare difficult because the ulnar and radialextensors are paralyzed. The proximalphalanges of the four fingers cannot beextended because of the involvernent ofthe extensor digitorum communis; thethumb cannot be extended or abductedbecause of the paralysis of the abductorpollicis longus and of the extensors pol-licis longus and brevis. The bulge of thedorsal forearm group of muscles ( exten-sor-supinator group ) is flattened or evenhollowed. There is absence of the peri-osteal reflex on tapping the radius.

Seperance of tr[eclian Nense

While sensorll examination will revealvarving degrees of hypesthesia and anes-thesia as outlined in the medial nerve

'lsr PHALANX

COTLATERAL LIG.CORDLIKE PART

FANLIKE PART

VOLARACCESSORY LIG.

METACARPATBONE

THE COLLATERALAND VOLAR ACCESSORYLIGAMENTS IN ATYPICAL DIGIT

F I G U R E 4 I

HAND IN THE, ,POSITION OF FUNCTIOI .

LUMBRICAL MUSCIINTEROSSEOUS MUSCTE

C I B A

\I THE IIAND OF RADIAL,

ULNAR NERVE LESIONS

dial Nerue

r frequency of arm injuries

:r dislocations and frac-

Lrgical neck and middle

merus, the radial is the' injured of these three(

ination will reveal hypes-

r along the dorsum of the

alf the width indicated in

rlso on the hand in most'ammed in Figures 18 and

sually anesthesia of there first dorsal interosseous

wtion reveals the typical

rsition of the hand. The

cn of the thumb and the

lready fexed hand makes

ngers somewhat difficult.

t be extended at the wrist,

movements of the hand

ause the ulnar and radial

raralyzed. The proximal.e four fingers cannot bese of the involvement ofigitorum communis; the

re extended or abducted

paralysis of the abductor

lnd of the extensors pol-brevis. The bulge of the

group of muscles (exten-

oup) is flattened or even: is absence of the peri-tapping the radius.

zdian N eroe

7 examination will revealof hypesthesia and anes-

red in the medial nerve

'lst PHALANX

COTLATERAL LIG.CORDLIKE PART

FANLIKE PART

VOLARACCESSORY LIG.

METACARPALBONE

THE COLLATERALAND VOLAR ACCESSORYLIGAMENTS IN ATYPICAL DIGIT

LUMBRICAL MUSCLE

INTEROSSEOUS MUSCLE

F I G U R E 4 I

H A N D I N T H E

F I G U R E 3 7

ANTERIOR DISLOCATION OFPROXIMAL PHALANXDUE TO DIVISION OFCOLLATERAL LIGAMENTS

FIGURE 39

FRACTURE OFMETACARPALBONE. FLEXIONDEFORMITYCAUSED BYPULL OFINTEROSSEOUSMUSCLE

DEFORMITY DUE TO PULL OFLUMBRICAL AND INTEROSSEOUSMIJSCLES IN FRACTURE OFPROXIMAL PHALANX(HOOD REMOVED)

F I G U R E 4 0

F I G U R E 3 8

C I B A , ,POSITION OF FLJNCTION"

areas of Figures 18 and 19, complete anes-thesia will usually be present only on the

palmar and dorsal aspects of the terminal

phalanges and parts of the middle pha-langes of the index and middle fingers.

In a previolrs paragraph, it was sug-gested that the median nerve could alsobe known by its functional name: theflexor - pronator - thumb - finger - approxi-mator nerve. In a general way, this namesummarizes the motor control of the nerveancl suggests what to expect in divisionof the nerve.

LIotor examination in a case of sever-ance of the median nerve just above theelbow reveals weakness in wrist-fexionbecause of paralysis of the powerful flexorcarpi radialis muscle. The flexor carpiulnaris ( innervated by the ulnar nerve )has a tendency to flex the wrist ulnarward.There is inability to flex the thumb, index,and middle fingers. Pronation is veryweak because the pronator radii teres(round pronator) and the pronator quad-ratus ( square pronator ) muscles are par-alyzed. Because the thenar eminencemuscles are paralyzed, there is consider-able difficulty in trying to approximatethe tip of the thumb successively to thetips of the fingers. In attempting to claspthe unaffected hand, the index and mid-dle fingers will not fex as will the otherfingers. With the hand flat on a desk, theindex finger cannot scratch the desk.

Inspection reveals a hollowing-out ofmost of the normal forearm muscle bulgeof the volar or flexor-pronator group ofmuscles and a hollowing-out of the thenareminence or thumb-finger-approximatormuscle group.

It is easy to appreciate the importanceof the median nerve, since it has most ofthe motor and sensory control of thethumb, index, and middle fingers. It is no

9B

wonder that causalgia, which seems toafiect this nerve more than others, is sucha painfully disabling affiiction.

Seoerance of tlrc Ulnar Neroe

Sensory exarnination' reveals varyingdegrees of hypesthesia and anesthesia ofthe ulnar border of the hand and the volarand dorsal aspects of the fifth finger andulnar half of the fourth finger, Figures18 and 19. Total anesthesia is noted usu-ally in the fifth ffnger.

Motor Examination; If the division ofthe nerve is trbove the elbow, there is lossof ulnar flexion due to paralysis of theflexor carpi ulnaris (ulnar fexor) and ina-bility to flex the terminal phalanges of thefourth and fifth fingers because of paraly-sis of the ulnar half of the flexor digitorumprofundus muscle.

Since the ulnar nerve supplies the hypo-thenar eminence muscles, the interosse-ous muscles, the two medial lumbricalmuscles, the adductor pollicis muscle, andthe deep head of the flexor pollicis brevismuscle, there is a marked weakness orIoss of the so-called finger-spreading andapproximating movements of the fingers.There is inability to scrape the thumbacross the palm as well as the inability toform a perfect "O" with the thumb andindex finger. It is also difficult to holdtightly a piece of paper between thethumb and index finger.

Inspection will reveal a hollowing-outof the hypothenar eminence and themuscle bulges of the interosseous musclesbetween the metacarpals. The normalbulge along the proximal ulnar border ofthe forearm will also be flattened due toatrophy of the flexor carpi ulnaris and theulnar half of the fexor digitorum pro-fundus muscles.

The so-cal led "c law-hand" is most

noticeable when the ulnarin the distal half of the f<it has given motor branccarpi ulnaris and especi;half of the fexor digitrThe extensor digitorumplied by the radial nerveproximal phalanges of th,fingers. The ulnar half otorum profundus (supplnerve ) will flex the ternphalanges, thus producposition of the fourth anr

Seaerance of Median anc

S ensory exami.nation rramount of hypesthesia athe palm and of the vaspects of the fingers asures 18 and 19.

The findings in the mtdepend upon the level at,are cut. If severed abovtentire flexor-pronator otgroup of muscles, andmuscles of the hand wiWith the f exors carpi racparalyzed, the extensorrlongus and brevis andulnaris ( supplied by ra<tend to extend and slighhand at the wrist.

The extensor digitorunhyperextend the proximathe thumb abductor an<abduct the thumb and pslightly dorsal to that olparalysis of the intrinsichand causes a fattening cmetacarpal arches, creatlike" hand. The subsequerthe fexors digitorum pr,the sublimis and flexor poduces a moderate "claw"

C L I N I C A L S Y M P O S I AC I B A

t_lsalgia, which seems tomore than others, is suchling affiiction.

Ulnar Neroe

,ination ' reveals varying

;thesia and anesthesia of

of the hand and the volar:ts of the fifth ffnger and

e fourth finger, Figures

anesthesia is noted usu-inger.

wti,on: If the division of,e the elbow, there is loss

due to paralysis of the'is (ulnar flexor ) and ina-

:erminal phalanges of the

ingers because of paraly-rlf of the flexor digitorum

: nerve supplies the hypo-

: muscles, the interosse-

e two medial lumbrical

uctor pollicis muscle, and

: the flexor po)licis brevis

a marked weakness or

led finger-spreading and

rovements of the fingers.

ty to scrape the thumb

as well as the inability to'O"

with the thumb and

is also difficult to hold

of paper between the

r finger.

I reveal a hollowing-out

nar eminence and the

the interosseous muscles

etacarpals. The normal

proximal ulnar border of

also be flattened due to

:xor carpi ulnaris and there flexor digitorum pro-

J "claw-hand" is most

noticeable when the ulnar nerve is severedin the distal half of the forearm; i.e., atterit has given motor branches to the flexorcarpi ulnaris and especially to the ulnarhalf of the flexor digitorum profundus.The extensor digitorum communis ( sup-plied by the radial nerve ) will extend theproximal phalanges of the fourth and fifthffngers. The ulnar half of the fexor digi-torum profundus (supplied by the ulnarnerve) will fex the terminal and middlephalanges, thus producing a claw-likeposition of the fourth and fifth fingers.

Seoerance of Median and Ulnar Neraes

Sensory examinati,on reveals a variableamount of hypesthesia and anesthesia ofthe palm and of the volar and dorsalaspects of the fingers as outlined in Fig-ures 18 and 19.

The findings in the rnotor examinationdepend upon the level at which the nervesare cut. If severed above the elbow, theentire flexor-pronator or volar forearmgroup of muscles, and all the intrinsicmuscles of the hand will be paralyzed.With the flexors carpi radialis and ulnarisparalyzed, the extensors carpi radialislongus and brevis and extensor carpiulnaris (supplied by radial nerve) wilitend to extend and slightly supinate thehand at the wrist.

The extensor digitorum communis willhyperextend the proximal phalanges, andthe thumb abductor and extensors willabduct the thumb and pull it in a planeslightly dorsal to that of the hand. Theparalysis of the intrinsic muscles of thehand causes a flattening of the carpal andmetacarpal arches, creating a frat "ape-

like" hand. The subsequent contracture ofthe fexors digitorum profundus and ofthe sublimis and flexor pollicis longus pro-duces a moderate "claw" position of the

C L I N I C A L S Y M P O S I A

fingers and thumb. If the nerves aresevered in the distal part of the forearm,i .e . , a f ter they have suppl ied motorbranches to the flexors of the ffngers, the"claw" position of the fingers will be verymarked. This is understandable when onerecalls that the extensor digitorum com-munis muscle (supplied by radial nerve)will hyperextend the proximal phalanges,and that the finger flexors, unopposed bythe paralyzed intrinsic hand muscles, willsharply flex the middle and terminal pha-langes,.thus producing an extreme "claw"

appearance of the fingers.

LIGAMENTS OF TIIE HAND

A thick but loose articular capsule holdstogether the saddle-shaped joint betweenthe first metacarpal and greater multangu-lar bone. Because of the conffguration ofthese articular facets, the thumb enjoys avery wide range of movement, in fact, thewidest range of movement of any of themetacarpal bones.

The bases of the second, third, fourth,and fifth metacarpal bones are heldtogether by dorsal, volar, and interosse-ous ligaments.

The volar surfaces of the heads of thesecond, third, fourth, and fifth metacarpalbones are connected by a tough fibrousband - the deep trq.nauerse metocarpalligament, Figures 30 and 32. This liga-ment and the dorsal, volar, and interosse-ous carpometacarpal ligaments give thehand stability. They per:rnit the fifth meta-carpal a thirty-degree range of movement,the fourth about fifteen degrees. Theypermit practically no mobility to the sec-ond and third metacarpal bones, therebymaking this the most stable part of thehand. The deep transoerse metacarpalligament helps preserve the metacarpal

C I B A 99

b---_

PARONYCHIA

FELON(sHowrNG rNctstoN)

SUBCUTANEOUS ABSCESS(NOTE I.OC,AL/ZED SWELLTNG)

TENOSYNOVITIS(DEMONSTRATTNG KANAVEL'S

4 CARDINAL POINTS)

FIGURE 42

TECHNIQUE IF LOCAL-IZED TO ONE SIDE

FIGURE 43

PUILING DOWN NAIL FIAP AFTER REMOVALAND EXCISING NAIL ROOT. OF NAIL ROOT

FIGURE 45

SAGITTAL SECTIONsHowrNG PUS (GREEN)BETWEEN SEPTA

MIDPALMAR SPACEINFECTION SECONDARY TOTENOSYNOVITIS OF MIDDLE(FOCUS rS TNFECTED LACERAAT DISTAL CREASE)

SCHEMATIC CROSS SECTIONsHowrNG HOW tNCtStONDIVIDES SEPTA

3

PATHOGENESIS OF"HORSESHOE ABSCESS"WITH RUPTUREINTO PARONA'SSUBTENDINOUSSPACE

FIGURE 44

^{ rrNoeRNess ALoNG SHEATH

MIDPATMAR

FIGURE 49

LYMPHEDEMA OFDORSUM, SECONDARY

TO PATMAR SPACE

nffiFIGURE 43

AFTER REMOVALOF NAIL ROOT

\Trc cRoss sEcTtoNNG HOW TNC|S|ONSEPTA

IAPfoT.

INFECTION SECONDARY TOTENOSYNOVITIS OF MIDDLE FINGER,(FOCUS IS INFECTED LACERATIONAT DISTAL CREASE)

1 SLIGHTI FLEXION

+, i't,'H''"il 11;'

lcrursrs orIESHOE ABSCESS"RUPTURETARONA',S

f DrNous

II

MIDPALMAR SPACE

THENAR SPACE INFECTIONFROM TENOSYNOVITISOF INDEX FINGER.(FOCUS rS DEEPPUNCTURE WOUND)

MIDPALMAR

4,{ffi/ ' f , '6l, I /sg1sgBUTTON ABSCESS

tarch, and its rupture weakens the hand to

a marked degree. As shown in Figtires 30

and 32, the lumbrical tendons lie on the

palmar aspect and the interosseous ten-

dons on the dorsal aspect of this ligament.

Mention should be made of the acces-

sorg aolar ligament and the two collateral

ligaments which strengthen the metacar-

pophalangeal joints. These are clinically

important because, whether by rupture or

capsulotomy, they may permit the base

of the proximal phalanx to slide onto the

palmar aspect of the head of the meta-

carpal bone, thereby creating a painfullydisabling condition in the hand, Figures

37 and 38.

TENDON AND MUSCLE SI{EATHS

OF TIIE IIAND

Figure 54 shows the palmar creases.

Figures 4,5,28, and 29 show the tendon

sheaths of the second, third, and fout'thfingers. In most hands these sheaths ex-

tend from the terminal phalanges approx-

imately to a line drawn across the palm

from the medi,al end of the distal palmar

crease to the lateral end of the proximal

crease. Note how the proximal ends of

these sheaths overlie the distal ends of

the thenar and midpalmar spaces or bur-

sae, Figures 28 and 29. Any one of these

sheaths occasionally may extend to the

wrist.If one remembers the extent of these

sheaths, it is not difficult to realize how a

suppurative tenosynovitis involving them

can account for Kanaoe|s four cardinal

points which are utilized in diagnosing

pus in flexor tendon sheaths. Figure 48

illustrates Kanarsel's four cardinal signs

and symptoms:

1. The finger is held in slight fexion for

comfor t . In contrast i t can be held

L02

straight without much pain in a local-

ized inflammation (furuncle ).2. The finger is uniformly srvollen in ten-

clon sheath infections in contrast to Io-

calized swelling in local inflammation.

3. Intense pain accompanies any attempt

to extend the partly flexed finger; this

is absent in local involvement.

4. Tenderness is marked along the course

of the inflamed sheath in contrast to its

absence in a localized inflammation.

The flexor sheath of the thumb usually

extends from the terminal phalanx to a

point two or three centimeters proximalto the proximal volar crease of the wrist.

The proximal half is commonly referred

to as the radial bursa, Figures 4, 24, 28,

and 29. Occasionally the proximal half of

the flexor pollicis longus sheath is sepa-

rated by a septum from the distal half of

the sheath, making them entirely separatesheaths.

The fifth-finger flexor sh,eath com-

mences at its terminal phalanx and, on

reaching a point half way up the palm,

expands laterally ( Figures 4, 5, 24, 28,

and 29) to envelop the tendons of the

fourth, third, and second fingers. This

expanded portion extends two or three

cent imeters prox imal to the proximal

volar crease of the wrist and is usually

called the ulnar bursa. Occasionally the

distal unexpanded part of the fifth-finger

sheath is separated by a septum from the

ulnar bursa.In a much smaller number of hands, the

sheath of the index finger may extend to

and communicate with the ulnar bursa.

The third-finger sheath or the fourth-

finger sheath may occasionally do this.

These are variations the surgeon should

always keep in mind. In a large number of

hands, a communication exists between

the radinl and, ulnar bursa. This accounts

for the so-cal led "horr

(Figure 49) following a ssynovitis of the thumb o

SIIBTENDINOUS

(ranoue's sr

The potential space br

poll icis Jongus tendon, tum profundus tendons, r

quadratus muscle is kn

tendinous space ol the'space. It is easy to see hc

pollicis longus sheath infrthe radial bursa and elinto this space. The sar:r:suppurative tenosynovittendon sheath of the fiftlbursa. Figure 24 shows Ifor pus from a thenar almar abscess to rupture inl

LUMBRICAL MUSCL

F i g u r e s 4 a n d 5 s h o ulumbrical muscles withopened first lumbrical shis adherent to the "roo

bursa or space with ropening into it. The sefourth lumbrical sheathseasily demonstrated, buusually overlie the midspace. Figures 25,28, atmat ica l ly these re lat isheaths extend from thecenter of the palm. They rmost easily in the handand are surprisingly str<being thin and semitransrecalled that the enshemuscles and flexor tendformed by septa fromneurosis, Figures 4,5, a:

C L I N I C A L S Y M P O S I ,C I B A

)ut mu('h fain in a local-

rt ion (furuncle ).uniformly swollen in ten-

'fections in contrast to io-

ng in local inflammation.

accompanies any attempt

partly f lexed finger; this

lcal involvement.rmarked along the course

d sheath in contrast to its

localized inflammation.

nth of the thumb usually

re terminal phalanx to a

ree centimeters proximalvolar crease of the wrist.

alf is commonly referred

bursa, Fig:rres 4, 24, 28,

nally the proximal half of

is longus sheath is sepa-

Lm from the distal half of

ng them entirely separate

ger flexor sheath com-

:rminal phalanx and, on

t half way up the palm,[y (Figures 4. 5. 24, 28,'elop the tendons of the

nd second fingers. This

rn extends two or three

oximal to the proximalthe wrist and is usually" bursa. Occasionally the

ed part of the fifth-finger

ted by a septum from the

rller number of hands, the

dex finger may extend to

rte with t}re ulnar bursa.

r sheath or the fourth-

ray occasionally do this.

tions the surgeon should

nind. In a large number of

unication exists between,lnar bursa. This accounts

for the so-cal led "horseshoe abscess"(Figure 49) following a suppurative teno-synovitis of the thumb or fifth finger.

SI.IBTENDINOUS SPACE

(eanoNa's seecn)

The potential space between the flexor

pollicis longus tendon, the flexor digitor-um profundus tendons, and the pronatorquadratus muscle is known as the sub-tendinous space of the wrist or Parona'sspace. It is easy to see how pus in a flexorpollicis longus sheath infection can ascendthe radial bursa and eventually ruptureinto [his space. The sflme cAn occur in asuppurative tenosynovitis involving thetendon sheath of the fifth ffnger and ulnarbursa. Figure 24 shows how it is possiblefor pus from a thenar abscess or midpal-mar abscess to rupture into Parona's space.

LUMBRICAL MUSCLE SI{EATIIS

Figures 4 and 5 show the ensheathedlumbrical muscles with a probe in theopened first lumbrical sheath. This sheathis adherent to the "roof" of the thenarbursa or space with no demonstrableopening into it. The second, third, andfourth lumbrical sheaths are not nearly soeasily demonstrated, but when present,usually overlie the midpalmar bursa orspace. Figures 25, 28, and 29 show sche-mat ica l ly these re lat ionships. Thesesheaths extend from the web-area to thecenter of the palm. They are demonstratedmost easily in the hand of a heavy toilerand are surprisingly strong despite theirbeing thin and semitransparent. It will berecalled that the ensheathed lumbricalmuscles and flexor tendons lie in canalsformed by septa from the palmar apo-neurosis, Figures 4, 5, and 25. From this

C L I N I C A L S Y M P O S I A

description, it is not difficult to visualizehow pus from a web-area infection canascend the first lumbrical canal and sheathand rupture into the thenar bursa or space;the second, third, and fourth rupture intothe midpalmar bursa or space. In the "pre-

antibiotic" days when serious hand infec-tions were more common, cases were seenin which pus from a thenar or midpal-mar space abscess would erode into anddescend a lumbrical sheath and canalfinally to rupture through the skin in the

dorsal web-area.

THENAR AND' MIDPALMAR SPACES

There is some disagreement about theexistence of these spaces. According toKanavel, the thenar space extends medio-laterally from the third metacarpal boneto the thenar eminence and proximodis-tally from the transverse carpal ligamentto a line about a thumb's breadth prox-imal to the webs of the fingers. The mid-

palmar space extends lateromedially fromthe third metacarpal bone to the hypo-thenar eminence and proximodista l lyabout a centimeter more proximally than

the thenar space. Figures 24,25,28, and29 show schematically the approximateextent of these spaces.

The use of the word "space" in the terms

thenar space and midpalmar space is notentirely accurate. They are only potentialspaces, demonstrable only when injected

with a radiopaque fluid. Figures 4, 5, and24 show rents in a thin, almost transparent,membranous layer colored green. In orderto depict these so-called spaces in relationto surrounding structures, the artist hadto make the membranes appear muchthicker than they actually are. In fact,they are so thin that, unless extreme careis taken in palmar dissection, the mem-

C I B A i03

o'tffi

brane covering the thenaremoved with the skinfascia. This no doubt ,infrequency with whichseen. With careful dissectransparent membrane rdemonstrated. In fact, tlthese figures from a diss

probes in the rents of theering the so-called thenaspaces" As stated prevdemonstrated best in hrdone hard and roughreason, it seems logicalmembranes as parts ofwhich develop as a resull

tion to which laborers'jected. Therefore, why rtherwr and midpalmar I

purposeless spaces?Recall that in the fin

the proximal palmar andflexor tendons have shealmake their sliding moverure 24. Unlike the flexothumb and fffth ftnger, wland bursae, the fexor terond, third, and fourth fi

or no sheath or bursal prcentral palmar portions.and 25 show how the ther

posed between the deeindex-fi nger fexor tendonfirst lumbrical muscle, araspect of the adductorAlso, note in Figure 5 adorsal extension of the

space interposed betweerof the adductor poll icispalmar aspect of the first

ous muscle, the second r

and the first palmar inteFigure 24 shows the er

butting against the pror

C L I N I C A L S Y M P O S I ,

TENDONSHEATHS

MIDPALMARSPACE

RADIAL ANDULNAR BURSA

(PROXTMAL ENDS)AND PARONA'S

SPACE

MOTOR BR,ANCHOF MEDIAN NERVETO THENARMUSCLES

ti,iY;;F IGURE 54

COMMONLY USEDINCISIONS IN HANDINFECTIONS

F IGURE 55

@W

VOLAR DIGITALARTERY AND NERVE

THENARSPACE

brane covering the thenar space is usually

removed with the skin and superficial

fascia. This no doubt accounts for the

infrequency with which this membrane is

seen. With careful dissection, a thin, semi-

transparent membrane can be definitely

demonstrated. In fact, the artist sketched

these figures from a dissected palm with

probes in the rents of the membranes cov-

ering the so-called thenar and midpalmar

spaces. As stated previously, they are

demonstrated best in hands which have

done hard and rough work. For that

reason, it seems logical to think of these

membranes as parts of modified bursae

which develop as a result of the extra fric-

tion to which laborers' palms are sub-jected. Therefore, why not call them the

thenar and midpalmar bursae instead of

purposeless spaces?Recall that in the fingers proper and

the proximal palmar and wrist regions, the

flexor tendons have sheaths and bursae to

make their sliding movement easier, Fig-

ure 24. Unlike the fexor tendons of the

thumb and fifth finger, which have sheaths

and bursae, the flexor tendons of the sec-

ond, third, and fourth fingers have little

or no sheath or bursal protection in their

central palmar portions. Figures 4, 5, 24,

and 25 show how the thenar bursa is inter-

posed between the deep aspect of the

index-ffnger fexor tendons, the ensheathed

first lumbrical muscle, and the superficial

aspect of the adductor pollicis muscle.

Also, note in Figure 5 a probe within the

dorsal extension of the thenar bursa or

space interposed between the deep aspect

of the adductor pollicis muscle and the

palmar aspect of the first dorsal interosse-

ous muscle, the second metacarpal bone,

and the first palmar interosseous muscle.

Figure 24 shows the end of the probe

butting against the proximal end of the

C L I N I C A L S Y M P O S I A

thenar bursa.

Figures 5 and 24 show a rent in the

membrane covering the so-called midpal-

mar space. Actually, there is no space

here; it is also a potential space in what

can be more logically called the midpal-

mnr bursa. This bursa is not nearly so easy

to expose as the thenar bursa; and, simi-

larly, it can be demonstrated only in a

hand that has done hard, rough work.

Figure 24 shows probes butting against

the proximal ends of the thenar and pal-mar bursae.

The author has had an opportunity to

dissect many hands, varying from those of

delicate type to those which have obvi-

ously been exposed to hard, rough usage.

In the former, the thenar bursa could usu-

ally be exposed, but the midpalmar bursa

could not be demonstrated satisfactorilyenough to be called a bursa. In the strong,

tough hand, however, there was consist-ently a thenar bursa and usually a mid-

palmar bursa - or excellent imitations of

bursae.

Considering the tremendous amount of

friction to which the palm is subjected, it

seems natural enough to have a thennr

bursapresent to enhance the sliding move-

ments of the index-finger flexor tendons

and ensheathed first lumbrical muscle over

the underlying adductor pollicis muscle.'[he thenar bursa also minimizes fric-

tion between the adductor pollicis and

that part of the palmar skin between the

index-finger tendons and thenar eminence.

The dorsal extension of the thenar bursa

makes smoother the movements between

the adductor pollicis and the ffrst dorsal

interosseous muscle. the second metacar-

pal bone, and the first palmar interosseous

muscle. Similarly, the midpalmar bursa

when present minimizes friction between

the fexor tendons of the third, fourth, and

105

fifth fingers, the ensheathed lumbricalmuscles, the underlying metacarpal bones,and interosseous muscles. As stated pre-viously, in delicate hands both bursaeseem to be absent or very difficult todemonstrate.

Figures 4, 5, and 24 show a sizableulnar bursa. However, it fails to cover allof the palmar portions of the flexor ten-dons - especially that part of the palmwhere these tendons are subiected to con-siderable pressure and fricti,on,

F igu res 4 ,5 ,24 ,25 ,28 , and 2g showsomewhat schematically how the proxi-mal end of the index-finger sheath and thesheath of the ffrst lumbrical muscle are incontact with the thenar bursa. The proxi-mal ends of the third, fourth, and fifthtendon sheaths. and associated lumbricalsheaths and canals are in contact with themidpalmar bursa. This enables one tounderstand how a suppurative tenosyno-vitis of the index-finger tendon sheath canrupture through its proximal end into thethenar bursa if present and cause theso-called thenar-space abscess, the clinicalappearance of which is shown in Figure53. On the same page is shown a midpal-mar space abscess which can be producedby rupture of a suppurative tenosynovitisof the sheaths of the third, fourth, or fffthffngers into the so-called midpalmar bursa.

As previously mentioned, the loose areo-lar tissue of the dorsalsubcutaneous spaceis loaded with minute lymph vessels whichreceive much of the lymph from the fin-gers, web-areas, and edges of the palm.Such lymphedema caused by a palmarspace infection is shown in Figure 51.This occurs quite commonly and is onoccasion mistakenly incised. The dorsalsubaponeurotic space is an area not fre-quently involved in hand infections.

A clear picture of the muscle and ten-

106

don sheaths, the thenar and midpalmarspaces or bursae and their locations, andtheir extent and relation to each othershould make it much easier to visualizethe anatomic course which can be takenby acute pyogenic infections of the hand.

Figure 49 shows the uniform swellingwhen the tendon sheath of the ,""ondlthird, or fourth finger is infected anddepicts by arrows the spread of a suppu-rative tenosynovitis from the flexor pol-licis longus sheath and radial bursa via theintermediate sheath to the ulnar bursa,fffth-finger sheath with eventual ruptureinto Parona's subtendinous space.

Figure 50 illustrates the appearance ofa midpalmar abscess following a suppura-tive tenosynovitis of the third finger. Theappearance of the palm is similar whenabscess is due to infection of the fourthfinger.

Figure 53 shows a thenar abscess withits swollen thenar area and abductedthumb resulting from an index finger sup-purative tenosynovitis. In Figure 5l isshown the dorsal lymphedema which maydevelop with either thenar or midpalmarabscesses. Figure 52 illustrates how a sub-cutaneous abscess in the palmar web-areacan erode through the palmar aponeurosisto reach the dorsum of the web-area toform a so-called "collar button abscess."

SURGICAL INCISIONS

Most surgeons prefer a general anes-thetic for the patient and the use of atourniquet (a blood pressure cufi infatedto 250 mm. ) to obtain a bloodless ffeld. Itis axiomatic that the incision should beadequate and properly placed, and thatutmost care be exercised in handling thesmall nerves, tendons, joints, and Jtherpertinent structures. It goes without say-

ing that chemotherapy, I

tion, position of function t

physiotherapy be includttreatment.

Some of the more comrsions are illustrated in F

44, 46,54, and 55.In treating paronychia

nof necessary to use an in

proximalward on the dorr

phalanx. Figure 42n showelevating the skin from t}

proximal end of the naidrop or two of pus found i

of a paronychia. This, '

therapy of heat, rest, aniusually cures the infectic

Should a paronychia be

stage of abscess formatiotof the nail, gentle elevatof the skin, Figure 43, ancor all of the loosened root

supportive therapy handadequately.

A felon is no longer <mouth" or "hockey stick"have been replaced byincision, Figures 44 and tthe formation of a tenderger tip.

Figure 54 shows the plrsions for draining a suppuoitis of the second, third,Observe that the incisionr

placed at the dorsal l imcreases in order to avodigital nerves and arteryure 55.

The dotted line on thFigure 54 represents theincision as it is on the rafifth finger. The reason fothe radial side of the fifthside of the second finge:

e thenar and midpalmar: and their locations, andd relation to each othermuch easier to visualize,urse which can be takenric infections of the hand.

rws the uniform swellingrn sheath of the second,r f inger is infected andi's the spread of a suppu-dtis from the flexor pol-lh and radiai bursa via theeath to the ulnar bursa,th with eventual rupturebtendinous space.strates the appearance ofcess following a suppura-Ls of the third finger. Thehe palm is similar wheno infection of the fourth

ws a thenar abscess withrar area and abductedfrom an index finger sup-rovitis. In Figure 51 islymphedema which mayher thenar or midpalmarr 52 illustrates how a sub-;s in the palmar web-areah the palmar aponeurosis'sum of the web-area to" collnr button ab scess."

CAL INCISIONS

; prefer a general anes-rtient and the use of arod pressure cufi infatedbtain a bloodless field. It: the incision should be'operly placed, and thatxercised in handling therdons, joints, and otherres. It goes without say-

ing that chemotherapy, heat, rest, eleva-

tion, position of function (Figure 41), and

physiotherapy be included in the plan of

treatment.

Some of the more commonly used inci-

sions are illustrated in Figures 42s, 43t,

44,46,54, and55.In treating paronychia, as a rule, it is

??ot necessary to use an incision extending

proximalward on the dorsum of the distal

phalanx. Figure 42n shows the knife-point

elevating the skin from the dorsum of the

proximal end of the nail to release the

drop or two of pus found in the early stage

of a paronychia. This, with supportive

therapy of heat, rest, and chemotherapv,

usually cures the infection.

Should a paronychia be advanced to the

stage of abscess formation under the root

of the nail, gentle elevation of the edge

of the skin, Figure 43, and excision of part

or all of the loosened root of the nail, plus

supportive therapy handles the situation

adequately.

A felon is no longer drained by "fish

mouth" or "hockey stick" incisions. These

have been replaced by a simple lateral

incision, Figures 44 and 46, which avoids

the formation of a tender scar on the ffn-

ger tip.

Figure 54 shows the placement of inci-

sions for draining a suppuratioe tenosyno-

uitis of th,e second, thi,rd, or fourth finger.Observe that the incisions are along lines

placed at the dorsal limit of the finger-

creases in order to avoid injuring the

digital nerves and artery depicted in Fig-

ure 55.The dotted line on the fifth finger in

Figure 54 represents the position of theincision as it is on the radinl side of the

fifth finger. The reason for the incision onthe radial side of the fifth finger and ulnar

side of the second finger is obvious: to

C L I N I C A L S Y M P O S I A

have the scars where they will be sub-jected to the least friction and trauma.

The incision for draining a thenar

ab,scess is placed on the dorsal aspect of

the web between the thumb and index

finger, Figure 55.

The incision for draining a midpalmar

abscess is shown on Figure 54. This inci-

sion can be made along or slightly proxi-

mal to the dirtal palmar crease. Once

through the palmar aponeurosis en route

to the more deeply situated midpalmar

abscess, it is important for the surgeon to

avoid injuring the digital branches of the

medial and ulnar nerve shown in Figure 7.

Pus from a suppurative tenosynovitis of

the fifth-finger sheath may progress proxi-

mally to the ulnar bursa extending from

the palm to a point four or five centi-

meters proximal to the crease of the wrist.

Figure 54 depicts the three incisions which

might be necessary to promote adequate

drainage. Certainly the incision along the

radialborder of the fifth finger and radial

border of the hypothenar eminence would

be required. If swelling and tenderness

are presented cephalad to the proximal

wrist creasd, a third incision extending

five centimeters proximally from the

crease and along the medial border of the

ulna would be necessary. These three inci-

sions usually allow eficient drainage.

Figures 24 and 28 demonstrate the

pathway of pus from a thumb sheath

infection to the proximal end of the radial

bursa - four or five centimeters cephalad

to the proximal crease of the wrist. In

Figure 54 is seen an incision for opening

the flexor pollicis longus sheath and the

distal part of the radial bursa.

To avoid injuring branches of the

median nerve that supply the thenar mus-

cle, it is best not fo extend the incision

along the ulnar border of the thenar emi-

C I B A 107

nence proximally beyond the mid-point of

the first metacarpal bone. To go fartherjeopardizes the motor branches of the

median nerve, Figure 54. If swelling and

tenderness are noted over the proximalend of the radial bursa, it can be drained

by using the same incision suggested for

draining the proximal end of the ulnar

bursa, Figure 54, or, as some surgeons

prefer, a similarly placed incision on theradial side - making sure to hug the lat-eral border of the radius to avoid cuttingthe radial artery.

If pus from either the ulnar or radial

bursa ruptures into Parona's subtendi-nous space (between the flexor tendonsand pronator quadratus muscle, Figure23), it can be drained by the same inci-

sion used for releasing pus from the proxi-mal end of the ulnar bursa, Figure 54.

The so-called "horseshoe abscess," Fig-ure 49, has to be drained by a combina-tion of fifth finger-ulnar bursa and fexor

pollicis-radial bursa incisions as depictedin Figure 54.

Infection from a human bite poses asomewhat difierent problem. The pres-ence of anaerobes with the usual strepto-cocci and staphylococci alters the patternof treatment. The metacarpophalangealjoint and adjacent tissues and spaces aremost commonly involved because theteeth of the opponent are struck with theknuckle of the clenched fist. When thehand is unclenched. the skin woundretracts proximally covering the deeperpart of the wound within which the bac-teria have been deposited. Obviously, thisairless, traumatized areaforms an ideal sitein which anaerobic organisms can fourish.

Treatment calls for excising a few milli-meters of devitalized skin and underlyingtraumatized tissue so as to lay the woundwide open for thorough surgical cleansing

of the tissues with generous amounts ofnormal saline solution. Penicillin usu-ally helps to subdue the streptococci andstaphylococci but exerts no effect uponthe anaerobes. Based on the theory thatnascent oxygen helps overcome the anaer-obes, Meleny has suggested the use ofmoistened zinc peroxide powder. Theother principles of treatment are the sameas outlined for tendon sheath and fascialspace infections, i.e., adequate heat, ele-vation, and rest with the hand splinted inthe position of function, Figure 41.

If a tendon has been severed, no attemptshould be made to repair it at the time ofthe cleansing procedure. It is best to waituntil several weeks after the .wound has

completely healed.If a bone has been involved, no attempt

should be made to curette the infected

part. It is better to let the sequestrumseparate spontaneously, thereby minimiz-ing the chances of spreading the infection.

TREATMENT OF IIAND INIURIES

It goes without saying that the detailedtreatment of the various types of injurieswhich beset the hand cannot be includedin this article; but, as in the paragraphsdealing with the treatment of hand infec-tions, the general principles involved willbe briefy described.

The ideal time to clean any recently sus-tained wound is the ftrst time. Therefore.the immediate emergency treatmentshould consist of no more than the appli-cation of a sterile dressing (with pressureif there is bleeding) and immobilizationwith a splint. The patient should be takenat once to a well-equipped dressing roomor operating room,where gloved, gowned,and masked, the surgeon can do a thor-ough job of cleansing so as to permit pri-

mary closure, if conditi,Before the advent of

duration of the so-called'for treatment of an averaincised. contaminated wc

eight hours after the inju

period, a wound with nosue or gross foreign bodier

which the devitalized tisbodies can be removed

should be g iven a thorcleansing with generous r

mal saline solution sloshrwound with a piece of garor anything hard ). If therindications, a primnry clotmade. While antibioticsextension of the "Gold

several hours, the generremoval of devitalized tis

bodies, followed by thorcgical cleansing of the wor

Within the "Golden Itendons or nerves can uslif the wound has beercleansed. Because of lostendon or nerve ends sobe approximated with tl

position of function. Themay then have to be flexas the case may be, in ormate the ends of these strtension.

The sutures approxin

edges should not be undsafer to apply a split grasurface than to have I

suture line.

The so-called secondnr,used if the wound is see"Golden Period" has elalthis time, the wound is 5oughly cleansed with geof normal saline solution i

vith generous amounts of

solution. Penicillin usu-

bdue the streptococci and

rut exerts no effect upon

Based on the theory that

helps overcome the anaer-

has suggested the use of

: peroxide powder. The

iof treatment are the same

tendon sheath and fascial

s, i.a., adequate heat, ele-

:with the hand splinted in

function, Figure 4I.

rs been severed, no attempt

l to repair it at the time of

rocedure. It is best to wait

eeks after the .wound has

led.

been involved, no attempt

le to curette the infected

:er to let the sequestrum

,neously, thereby minimiz-

of spreading the infection.

YT OF rrAND rNJttRrES

ut saying that the detailed

e various types of injuries

: hand cannot be included

but, as in the paragraphse treatment of hand infec-

al principles involved will'ibed.

,e to clean any recently sus-

s the fust time. Therefore.

e emergency treatment

rf no more than the appli-

Lle dressing (with pressureding) and immobilization

he patient should be taken

ll-equipped dressing room

)m, where gloved, gowned,re surgeon can do a thor-

ansing so as to permit pri-

mary closure, if conditions warrant it.

Before the advent of antibiotics, the

duration of the so-called "Golden Period"

for treatment of an average lacerated or

incised, contaminated wound was six to

eight hours after the injury, During this

period, a wound with no devitalized tis-

sue or gross foreign bodies (or a wound in

which the devitalized tissue and foreign

bodies can be removed with certainty)

should be g iven a thorough surg ical

cleansing with generous amounts of nor-

mal saline solution sloshed gently in the

wound with a piece of gauze (not a brush

or anything hard). If there are no contra-

indications, a primary closure can then be

made. While antibiotics have permittedextension of the "Golden Period" by

several hours, the general principle of

removal of devitalized tissue and foreign

bodies, followed by thorough, gentle sur-

gical cleansing of the wound still applies.

Within the "Golden Period." severed

tendons or nerves can usually be sutured

i f the wound has been sat is factor i ly

cleansed. Because of loss of tissue, the

tendon or nerve ends sometimes cannot

be approximated with the hand in the

position of function. The hand or fingers

may then have to be flexed or extended,

as the case may be, in order to approxi-

mate the ends of these structures without

tension.

The sutures approximating the skin

edges should not be under tension. It is

safer to apply a split graft over the raw

surface than to have tension on the

suture line.

The so-called secondnry closure can be

used if the wound is seen iust after the"Golden Period" has elapsed. If seen at

this time, the wound is gently and thor-

oughly cleansed with generous amounts

of normal saline solution (soap and water

C L I N I C A L S Y M P O S I A

if there is grease in the wound) and then

a gauze pack moistened in normal saline

is placed in the wound. After 24 to 48

hours, the pack is removed and the wound

inspected. If the tissues look clean and

viable, closure is then made with fine silk

sutures.

Following either primary or secondary

closure, the hand is adequately dressed

and put in the position of function in a

comfortably applied splint. The treatment

of extensive injuries with much loss of

skin or segments of tendons, nerves, or

muscles is much more compl icated.

Hence, the reader is referred to articles

and books by the authors mentioned in

the conclusion below.

CONCLUSION

Regardless of the pathologic change

that one encounters in the hand, it is

quite obvious that intelligent treatment

demands, ffrst of all, a sound knowledge

of structure. Therefore. this article has

been designed simply as a review of the

surgical anatomy. The author has men-

tioned only enough of the pathology and

surgery to assist in visualizing the perti-

nent anatomy.The reader who expects to be charged

with responsibility for surgical proce-

dures involving the hand is referred to the

works of Kanavel, Auchinchloss, Koch,

Mason, Bunnell, Littler, and others who

have outlined in far greater detail the

management of infections and the various

complicated procedures that are neces-

sary for the rehabilitation of hands that

have been badly damaged.

Brief as this article has been, the author

hopes that it will help the reader to visual-

ize, and to remember, the rather intricate

details of the surgical anatomy of the hand.

C I B A 109

-F6-.t.EE'

provides more'livingtimei forthehypdrtensive

withtlsixke1action.Increiblood 1.Slows.Mainlblood 1.Relier.Calm.Loweeffecti'Fot prcscribing intomation, plei

- c )is)reor thee

with thesesix keyactions.lncreases renalblood flow.Slows rapid heart rate.Maintains cerebralblood flow.Relieves edema.Cal ms tense patients"Lowers blood pressureeffectively

Fot prescribing intormation, piease see back covet fold-out page.

{

LOCACORTEN%VIOFORM'modern skin therapythat elicitsexcellent response

Stops itchingand burningRelievesinflammationQuickly

o Promotes healingo Prolonged in effecto Broad spectrum of actiono Well toleratedo Sensitizalion is rareo Virtually non-toxic

DRAMATIC

ffiilffiFor pre

DOSAGEOne or two tab le tthen ad jus t as neelowest effective d(

Prescribing Note

Ser-lI N DI CATI ONSHyper tens ion , espanx ie ty , impa i rededema.

SI DE-EFFECTSThe s ide e f fec ts a lcomponent d rugs ,dosages o f each cthe f requency o f t l

Serpas i / ; Lass i tudd ia r rhea, inc reasercongest ion may b(headache, b izar reNasa l congest ion isecre t ions somet i rt rea ted w i th the d lsuch as top ica l apcons t r i c to rs and/ocomes th is p rob le l

Aprcsoline: Tachyld izz iness , weakne lhypotens ion , numlex t reml t ies , f lush i rt ion , con junc t iva lsymptoms, rash , dhemoglob in and r€and a lupus- l i ke s )cases fo l low ing ad

Esldr/xr Nausea, anr t rogen re ten t ion ,hypoka lemia . Rar€sk in rash , photosecy'tos\s.

CAUTI ONSSe/paslir Depressunmasked by resesomet imes ac t iveiza t ion fo r e lec t ro rd r u g s h o u J d b e w ie lec l rve surgery ; (E lec t roshock therdrawal o f the dru(w i t h d i g i t a l i s , q u i r

Apreso/ lne ; Use cadvanced rena l decerebra l i schemianarcotic effects ofPer iphera l neur i t i sn u m b n e s s a n d t i nPub l ished ev idencef fec t and add i t io ri f symptoms deve l

Esidrlx; With Esidand/or labora toryleve ls shou ld be scor rec ted . Excessprevented by adecporass um suppte lpa t ien ts on d iq i taadvanced rena l farecent card iac o r (d iabetes . Hydrochs iveness to exoge(norep inephr ine) €tubocurar ine . Hypanesthes ia have brece iv ing th iaz ider

Use SerAp-Es w l tcoronary artery dirvascu la r acc idents

CONTRAI NDICATFor Es id r ix , o l igurFor Serpas i l , a h is

S U P P L I E DTab le ts (p ink) , ea(( reserp ine) 0 .1 mghydroch lo r ide) 25ch lo ro th iaz ide) 15

L

INFECTED ECZEMABefore t reatment wi thLOCACORTEN-vtoFoF[,4

After 2 weeks't reatment wi thLOCACORTENVIOFORM

For p resc t ib ing in fa rmat ian , p /ease see back cover lo ld 'ou t page

f'

)FORM' Ser-Ap-EsPrescribing Notes

I N D I C A T I O N SH y p e r t e l s i o l , e s p e c i a l l y w h e n c o m p ' c a - e d b yanx ie ty , impa i red or degenera t ing rena l Junc t ion ,edema.

DOSAGEO n e o r t w o t a b l e t s , b . i . d . , i n i t i a l l y , f o r t w o v r ' e e k sthen ad jus t as needed. For ma in tenance, thel ^ , ^ / a a t a l f a . t \ / a d ^ . . ^ a

SI DE-EFFECTSThe s ide e f fec ts a re those o f the ind iv idua lc o m p o n e n t d r u g s , a i t h o u g h w i t h t h e r e d u c e ddosages o f each componen l in the combina t ionthe f requency o f the s ide-e f fec ts i s reduced.

Serpas l / r Lass i tude, d rows iness , depress ion ,d ia r rhea, Inc reased gas t r i c secre t ion , o r nasa lcongest jon may be ev ident . Ny 'o re ra re ly anorex ia ,h e a d a c h e , b r z a r r e d r e a m s , n a u s e a , d i z z l n e s s .Nasa l congest ion and increased t racheobronch ia lsecre t ions somet imes occur in bab les o f motherst rea ted w i th the drug . Symptomat ic t rea tment ,s u c h a s t o p i c a l a p p l i c a t i o n o f n a s a l v a s o -cons t r i c to rs and lo r an t ih is tamines usua l ly over -c o m e s t h i s p r o b l e m .

Apreso l ine : Tachycard ia , headache, pa lp i ia t ion ,d r z z i n e s s , w e a k n e s s , n a u s e a , v o m i t i n g , p o s t u r a lh y p o t e n s i o n , n u m b n e s s a n d t i n g l i n g o i t h ee x t r e m r t r e s , f l u s h i n g , n a s a l c o n g e s t i o n , l a c h r y m a -t i o n , c o n l u n c t i v a l i n j e c t i o n , d y s p n e a , a n g i n a lsymptoms, rash , d rug fever , reduc t ion inh e m o g l o b i n a n d r e d c e l l c o u n t , g i a n t u r t i c a r i a ,a n d a l u p u s - i i k e s y n d r o m e ( a r t h r a l g l a ) i n s o m ec a s e s f o l l o w i n g a d m i n i s t r a t i o n f o r l o n g p e r i o d s .

F s l d f l { r N a u s e a , a n o r e x . a . h e a d a c l e . e s r ' e s s n e s s ,n i t rogen re ten t ion , hyperur icemia , hyperg ycemia ,h \ p o r a l o n , a . R a r e v , l h r o r b o c y t o p e l c p - r p u a .sk in rash , photosens i t i v i t y , u r t i car ia and agranu lo-cy tos is .

CAUTI ONSSerpas / / : Depress ion may be aggravated orunmasked by reserp ine ; usua l ly revers ib le , bu ts o m e t i m e s a c t i v e t r e a t m e n t , i n c l u d i n g h o s p i t a l -i za t ion fo r e lec t roshock , may be needed. Thedrug shou ld be wt thdrawn two weeks pr io r toe l e c l , v e s u r g e ' y i o t h e l w i s e a d v , s e a l e s t h e t i s l .E lec t roshock therapy w i lh in seven days o f w i th -drawal o f the drug is hazardous . Use caut lous lyw i t h d i g i t a l i s , q u i n i d i n e o r g u a n e t h i d i n e .

Aprcsa l ine : Use caut ious ly in the presence o fadvanced rena l damage and recent coronary o rcerebra l i schemia . The drug may po ten t la te thenarco t rc e f fec ts o f barb i tu ra tes and a lcoho l .P e ' p h e r a l r e L r ' t : s , e v , d e . c e d b y p a ' e s r l - e s i a s ,n u m b n e s s a n d t i n g l i n g , h a s b e e n o b s e r v e d .P u b l i s h e d e v j d e n c e s u g g e s t s a n a n t i - p y r i d o x i n eef lec t and add i t ion o f py ldox ine to the reg imeni f symptoms deve lop .

Es ld r ry ; Wi th Es id r ix , jn p ro longed therapy , c l in ica land/or labora tory f ind ings fo r f lu id and e lec t ro ly tel e v e l b s l - o J ' d b e s t L d i e d r e g u a r l y , a 1 d i T b a l a n c e scor rec ted . Excess ive po tass ium loss can beprevented by adequate in take o f J ru i t ju ices orp o t a s s i u m s u p p l e m e n t s . U s e c a u t i o u s l y i npat ien ts on d ig i ta l i s , and in the presence o fadvanced rena l fa i lu re , impend ing hepat ic coma,recent card iac o r cerebra l i schemla , gout , o rd a b e t e s . H y d r o c h l o r o t h i a z . d e d a c r e a s e s r e s p o n -srveness to exogenous ly admin is te red Ievar te reno l(norep inephr ine) and increases respons iveness totubocurar ine . Hypotens ive ep isodes underanes thes ia have been observed in some pat ien tsrece iv ing th iaz ides . Use caut ious ly in p regnancy .

Use Set rAp-Es w i th caut ion in pa t ien ts w i thcoronary a r te ry d isease, a h is to ry o f cerebra lv a s c J J a . a c c i d e n l s , p e p t i c L l c e r .

CONTRAI N DI CATI ONSF o r E s i d r i x , o l i g u r i a o r c o m p l e t e r e n a l s h u t d o w n .For Serpas i l , a h is to ry oJ pept ic u lcer ; o r over tdepressr on .

S U P P L I E DTab le ts (p ink) , each conta in ing Serpas i l@(reserp ine) 0 .1 mg. , Apreso l ine@ (hydra laz inehydroch lo r jde) 25 mg. , and Es id r ix@ (hydro-ch lo ro th iaz ide) 15 mg. i bo t t les o f 100 and 500.

Slow-l(INDICATIONS A l l c i rcumstances in wh lchpotass ur sLpp lemenla l io r i s necessary . andpar t i cu la r ly dur ing pro longed or in tens ivedrure t ic therapy .

Patients at special risk are those wlth advanced hepat ic c r rhos is o r chronrc rena d isease, pa t ien ts w i th cons iderab le edema (par -l r u u a t l y ' J r r 1 a . y o u l p J l 5 , a r g e J . p a t e n t s o 1a sa t restricted diet and patients receiv ng dig-i ta ls (a lack o f po tass ium sens i t zes the myo-card ium to the tox ic e f fec ts o f d ig i ta l i s ) .

The range o f ind ica t ions fo r S ow-K may besu mmar zed as f o l lows

As a supp lement to d iu re t i csHypoch loremic a lka los isCush ing 's SyndromeStero id therapyL iver c l r rhos isD iseases charac ter ized by pers is ten t vom t ing

or o tarrneaD g italis therapyUlcera t ve co l i t i sSteatorrheaChron ic d ia r rheaReg iona l i le t i sCon l inuous w i thdrawal o f gas t ro in tes t ina l

f lu idsI eosro myNeoplasms or obstructions referable to the

g d J U u I r v 5 { i l r a u a L I

DOSAGE-The dosage is de le rmined accord-ing to the needs o f the ind iv idua pa t ien t .When admin is te red as a po tass ium supp le-ment dur ing d iu re t i c therapy , a dose ra t io o fone S low-K tab le t w i th each d iu re t i c tab le t w i l lusda l y su ' l i cp . ou l may be Increased as necessary In genera l , a dosage range be twee l2-6 S low K tab le ts (approx lmate ly 1 6 -48 mEqK +) da i l y , o r on a l te rna te days , w i l l p rov ideadequate supp lemenlary po tass lum in mostcases . Pre ferab ly , admln is te r a f te r mea ls .

Warning-A probable assoclation ex sts between the use o f coa ted tab le ts conta in ing po-tass ium sa ts , w i th o r w i thout th az ide d iu re t i cs ,and the inc idence o f ser ious smal l bowel u lcera t lon . Such prepara t ions shou ld be usedon ly when adequate d ie ta ry supp lementa t lonis no t p rac t ca l , and shou ld be d iscont lnued i fabdorn ina l pa ln , d i s ten t ion , n ausea, vomi t ingor gas t ro ln tes t ina l b leed ng occurs .

S IDE EFFECT-To da te , near lyI 000,000,000 tab le ts o f S ow K and CIBA thazide tab ets cofta ning the slow release po-tass ium core have been used. On ly one caseof smal l bowel u lcera t ion fo l low ing t rea tmentw i th a comb nat ion tab e t con ta in ng cyc lop e n l l - , a 1 d e . r e s e r o i n e . a n d K C r h a s b e e n r e -por led .

CAUTIONS-Admin is te r cau t ious ly to pa t ien tsin advanced rena l fa i lu re to avo id poss ib , le hy-perka lemia . S low-K shou ld be used w i th cau-t on in diseases associated with heart blocks nce in { reased sprJm po lass iJn may in

u c g r E c u r u , u u ^ .

CONTRAIN DICATIONS-Fena i impa i rmen lw i th o l igur ia o r azo temla , un t rea ted Add ison 'sD isease, myoton ia congen i ta , hyperadrena-l i sm assoc ia ted w i th adrenogen i ta syndrome,acute dehydra t ion , heat c ramps and hyperka-lemia o f any e t io logy .

SUPPLIED Tab le ts (pa le o range, coated)each conta in ing 600 mg. o f po tass ium ch lo -r ide in a s ow- re lease, iner t wax core ; bo t t leso f 1 00 and 1 000.

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INFECTED ECZEMABefore t reatment wi thLOCACORTEN-V IOFORM

After 2 weeks't reatment wi thLOCACOFTEN-V IOFORM

Presctibing Notes

LOCACORTENgVIOFORM'I N D I C A T I O N SLocacor ten-V io fo rm is recommended in thet rea tment o f sk in d isorders compl ica ted bybac ter ia l and/or funga l in fec t ions .Locacor ten-V io fo rm is recommended fo r con-t ro l l ing secondary in fec t ions , espec ia l l y thoseassoc ia ted w i lh occ lus ive dress ing therapy . l t i si n d i c a t e d i n :

d e r m a t o m y c o s i s l i c h e n s i m p l e x c h r o n i c u spyoderma a top ic dermat i t i sfo l l i cu l i l i s chron ic neurodermat i t i simpet igo nummular dermal i t i sl i chen p lanus in fec t ious dermat i t i ss t a s i s d e r m a t i t i s s e b o r r h e i c d e r m a t i t i sneurodermat i t i s eczemato id dermat i t i sacne anogen i ta l Prur i tusp s o r . a s i s c o n t a c t d e r m a t i t i sin te r t r ,go (dermat i t i s venenata)a n d m a n y s i m i l a r c o n d i t i o n s

Locacor ten-V io fo rm Cream has a s l igh t ly d ry ingef fec t , p r imar i l y use fu l fo r mo is t , weep ing les ionsand in in te r t r ig inous areas . The Oin tment i sespec ia l l y ind ica ted fo r d ry les ions accompan iedby th icken ing and sca l ing o f the sk in .

A P P L I C A T I O N A N D D O S A G ELocacor ten-V io fo rm shou ld be app l ied to theaf fec ted areas in a th in f i lm th ree or Jour t imesda i ly . The s i te may, i f necessary , be covered bya p r o t e c t i v e d r e s s i n g . T r e a l m e n t s h o u l d b econt inLed lo r a t leas t a few days a f te r c lear ingo f t h e l e s i o n s .

SI DE-EFFECTSRare ly , m i ld i r r i ta t ion . Wi th occ lus ive dress ings ,a few cases o f s t r iae o l the sk in have beenrepor ted . A l though ra re , a sens i t i v i t y to V io fo rmmay deve lop . l i an exacerbat ion or a l le rg ic typereac t ion occurs , t rea tment w i th Locacor ten-V o f o r m s h o L l d b e d : s c o n t i n u e d .

P R E C A U T I O N SVio form, as we l l as o ther iod ine-conta in ingcompounds, in te r fe res w i th some thyro id func t iont e s t s ( s u c h a s P B l , r a d i o a c t i v e i o d : n e u p t a k e a n db J - a 1 o l - e x t r a c t a b l e i o d i n e ) , w h : c h s h o u l dthere fore no t be per fo rmed w i th in a per iod shor te rthan th ree months Jo l low ing the use o i Locacor ten-V io fo rm. Other thyro id Junc t ion tes ts , such asthe T3 res in sponge tes l , o r the T ! de termina t ion ,are unaf fec ted by V io fo rm.

I n p r o l o n g e d o c c l u s i v e t h e r a p y , l h e p o s s i b i l i t y o fmetabo l ic sys temic e l fec ts shou ld be kepti n m i n d .

Locacor ten-V io fo rm may cause s ta in ing o f thes k i n , n a i l s , h a i r , o r f a b r i c s .

C O N T R A I N D I C A T I O N STubercu los is o t the sk in , ch icken-pox , p regnancy ,s k i n e r u p t i o n s f o l l o w i n g v a c c i n a t i o n , o r i n v i r a ld iseases o f the sk in in genera l . Locacor ten-Vro form shou ld no t be employed to t rea t eyed isorders , o r syph i l i t i c a f fec t ions o f the sk in .

S U P P L I E DCream, conta in ing 37o V io fo rm@ ( iodoch lor -hyd roxyq u i n ) a r d 0 .02o/o Locacor ten@ ( f I u m e th a .sore p iva la te ) i r a water -washab le base; tubeso f 1 5 a n d 5 0 G m .

Ointment, containing 37o Vioform@ and o.02o/oLocacor ten@ in a pe t ro la tum base i tubes o f1 5 a n d 5 0 G m . a n d j a r s o f 1 l b .

I N D I C A T I O N SOral: Mild to moderate depression/anxiety;fa t ;gue, le thargy ; d rug- induced sedat ion ,neuroses ; apathy , w i thdrawal ; m i ld sen i le con-{us ion , de tachment , and in func t iona l behav io rprob lems in ch i ld ren (hyperac t iv i t y , s tu t te r ing , e tc . )

Parenteral: Effective in sedative overdosageemergenc ies , has ten ing recovery f rom anes thes ia ,inc reas ing response to psychotherapy , a lcoho l ismand overcoming drug- induced Ie lhargy .

DOSAGEOtal:l n i t i a l l y , t w o 1 0 - m g . t a b l e t s i n t h e m o r n i n g , o n eat noon, and one more , i f necessary , a t 5 i00 p .m.For ma in tenance, rev ise as needed.

SI DE.EFFECTSNervousness or insomnia , i f p resent , can beavo ided by dosage- reduc t ion or by omi t t ingRi ta l in in the a f te rnoon. Repor ts no te a Jew casesof anorex ia , d izz iness , headache, pa lp i ta t ions ,drows iness , sk in rash , over t psychot ic behav io rand psych ic dependency .

CAUTI ONSNot recommended fo r severe depress ions , exceptin hosp i la l under c lose superv is ion . Pat ien ts w i thag i ta t ion may reac t adverse ly . Use caut ious ly inthe presence oJ marked anx ie ty o r tens ion .F l i ta l in may po ten t ia te the e f fec t o f p ressor agents iexerc ise care in use w i th ep inephr ine , levar te reno l ,o r a n g i o t e n s i o n a m i d e . W h i l e o r a l R i t a l i n h a sl i t t le o r no e f fec t on normal b lood pressure , usecaut ious ly in pa t ien ts \ ryho have hyper tens ion .R i ta l in i s s tab le indef in i le ly in l yoph i l i zed fo rmbu l shou ld be used w i th in 2 months a l te r theso lu t ion is p repared. Do no t in jec t Parentera lSo lu t ion th rough tub ing or a sy r inge wh ichconta ins a barb i tu ra te o r s t rong ly a lka l ineso lu t ion , s ince a heavy prec ip i ta te i s to rmed.

C O N T R A I N D I C A T I O N SG l a u c o m a , e p i l e p s y .

SIJPPLI EDAl l io rms conta in methy lphen ida te hydroch lo r ide .Tab le ts o f 10 mg. (pa le b lue , scored) ; bo t t les o l100 and 500.Tab le ts o ' 20 mg. (peach. scored) : bo t t les o f1 0 0 a n d 5 0 0 .A m p o u l e s o f 2 0 m g . ( l y o p h i l i z e d ) t b o x e s o f1 0 a n d 1 0 0 .

I WKa winnerfor'K-losers'

"Slow-K (pofassium chloride)tablets are the onlysaiisf,actory method ofgiving potassiu* by mouth."O ' D r s c o B . J , P o t a s s i u m C h l o r i d e w t h D u r e t c sB r t . l v e d . J ( l 9 6 6 ) , 2 3 4 8

Slow-Kslow-release potasslum chlor ide tablets

cSlow-K provides a steady K+ absorpt iono v e r 3 t o 4 h o u r s .

s For the 3-4 hours of Slow-K absorpt ion anyunder ly ing K* loss is countered , e .9 . ,dur ing diuret ic therapy

e SIow-K tablets are sugar-coated, palatableand easi ly swal lowed.r Slow-K contains Cl ion which is physiological lyessent ial to ensure K* absorpt ion andretent ion in pat ients with a tendency to developmetabol ic alkalosis,

And now CIBA introduces

r No b icarbonate in Slow-K which cannottherefore accentuate metabol ic a lka los is .

r Slow release of K + f rom Slow-K is lessl ike ly to produce hyperkalemia in cases ofrena l impa i rmen t .

r Each Slow-K tablet prov ides 600 mg.KCI (8mEqK+) rn an easi ly- taken tablet .

r S low-K is economical

C I B ADORVAL 780, QUEEECF a t p L a s c r D t n q t n l a r o t a l i a n f / . n s a s . . ' b i t . : k c a v e t l e l . l a u t D a g (