NOVEL THINKING

When assessing the distal peripheral nerve motor functions of the hand, try using this mnemonic: “Rock, Paper, Scissors”. Muscle Nerve 55(2):160–165, Kaplan EB, Smith RJ (1984) Kinesiology of the hand and wrist and muscular variations of the hand and forearm. Upper, If the metacarpophalangeal and proximal interphalangeal joints are stabilized as shown, flexion at the distal interphalangeal joint (flexor profundus) can be tested. In: Spinner M (ed) Kaplan’s functional and surgical anatomy of the hand, 3rd edn.

Mnemonics like this one that use simple terms like rock-paper-scissors help to integrate a thorough assessment into your routine physical exam. These areas are reliable because they are unlikely to be altered by variation or by overlapping of adjacent nerves. The combinations of movements by muscles innervated by the three peripheral nerves make up the gestures of “Rock, Paper, Scissors”. At the end of its descent along the anterior forearm, the median nerve is found midway between the styloid processes of the radius and ulna, medial to the flexor carpi radialis tendon and lateral to the palmaris longus tendon when this is present (see fig. They are inserted into the extensor expansions and, in certain fingers (see fig. Therefore, it is also called "labourer's nerve". The nerve then divides into superficial and deep branches. In combination with dorsiflexion at the wrist, the interossei and lumbricals produce the "Z-position" (fig.

doi:10.1016/j.hcl.2011.09.006, Harness D, Sekeles E (1971) The double anastomotic innervation of thenar muscles. Some of these variations are associated significant clinical consequences.

The four medial metacarpals are held together by a deep transverse metacarpal ligament related in front to the lumbrical tendons and behind to those of the interossei. The hand can be considered in four segments: Fingers: Digits that extend from the palm of the hand, the fingers make it possible for humans to grip the smallest of objects. The carpometacarpal joint of the thumb is an important, freely movable, saddle articulation with reciprocally shaped surfaces on the trapezium and first metacarpal. Injuries to the median nerve may be followed by severe, chronic sensory and trophic disturbances. The ulnar nerve enters the hand anterior to the flexor retinaculum (hence outside the carpal canal) and lateral to the pisiform. of images.

The material for this review was obtained by exploring PubMed and Google Scholar (search terms: hand innervation, variations of ulnar nerve, variations of median nerve, variations of radial nerve) as well as from standard anatomy texts. In clinical notes the fingers should be identified by name rather than by number: thumb (pollex), and index, middle, ring, and little fingers. 11-1). The nerve enters the hand by passing through the carpal tunnel, posterior to the flexor retinaculum and anterior to the flexor tendons to the index finger. Am J Phys Med 55(3):122–138, CAS  The median nerve (see fig. It is attached laterally to the tubercles of the scaphoid and trapezium and medially to the triquetrum, pisiform, and the hook of the hamate.

J Ultrasound Med 27(8):1129–1136, Belson P, Smith LK, Puentes J (1976) Motor innervation of the flexor pollicis brevis. Median Radial and Ulnar are also in alphabetical order, corresponding to Rock, Paper, Scissors, respectively. Reviewing the reference lists of significant papers uncovered further studies missed in the initial search. Tohoku J Exp Med 141(3):269–274, Lanz U (1977) Anatomical variations of the Median nerve in the carpal tunnel. At the end of its descent along the anterior forearm, the median nerve is found midway between the styloid processes of the radius and ulna, medial to the flexor carpi radialis tendon and lateral to the palmaris longus tendon when this is present, An important recurrent branch emerges almost immediately distal to the flexor retinaculum, is dangerously superficial, and supplies the abductor and flexor pollicis brevis and the opponens. 11-2, 11-3 and 11-4).

11-12).

B, The Z-position of the hand, produced by the interossei and lumbricals.

Uncontrolled infection (e.g., from a synovial sheath) may rupture into the central compartment and spread proximally into the forearm, anterior to the pronator quadratus muscle and its fascia. The traditionally taught innervation of the hand is also found to be highly variable. Anteriorward movement of the thumb as a whole, away from the palm, is called abduction (fig. -, J Hand Surg Br.

It originates from the brachial plexus, carrying fibers from the ventral roots of spinal nerves C5, C6, C7, C8 & T1.. It then enters the palm between the heads of the first dorsal interosseus. The deep branch of the ulnar nerve passes between the abductor and flexor digiti minimi, both of which it supplies. J Hand Surg Eur 34(2):212–214.

This initial search returned approximately 300 articles, which was reduced by abstract or title review.

These movements occur at all the joints of the thumb, although opposition takes place mainly at the carpometacarpal joint.

When assessing the distal peripheral nerve motor functions of the hand, try using this mnemonic: “Rock, Paper, Scissors”.  |  Google Scholar, Demircay E, Civelek E, Cansever T, Kabatas S, Yilmaz C (2011) Anatomic variations of the median nerve in the carpal tunnel: a brief review of the literature. The ring, middle, and index fingers are provided with digital sheaths that usually extend proximally no further than the necks of their metacarpal bones, leaving a gap of 1 to 3 cm below the common sheath. This post was reviewed by Daniel Ting and copyedited by Pouria Rezapour. In power grip, the extrinsic muscles provide the major force, the interossei are used as flexors and rotators at the metacarpophalangeal joints, and the thenar muscles are generally active.

Nerves of the Hand The nerve supply to a region is usually broken down into a superficial (or cutaneous) group and a motor group. Private Note. Basic Human Anatomy - O'Rahilly, Müller, Carpenter & Swenson. The short muscles of the thumb (fig. Copyright © 2020 Lineage Medical, Inc. All rights reserved. Comprehensive Summary of Anastomoses between the Median and Ulnar Nerves in the Forearm and Hand.

A very advanced study with numerous photomicrographs. The flexor carpi ulnaris in the arm flexes the hand. J Anat 109(Pt 3):461–466, Henry BM, Zwinczewska H, Roy J, Vikse J, Ramakrishnan PK, Walocha JA, Tomaszewski KA (2015) The prevalence of anatomical variations of the median nerve in the Carpal tunnel: a systematic review and meta-analysis.

The nerves of the hand are those vessels of the nervous system that innervate the hands and fingers. lateral ⅔ palm of hand; palmar aspect of lateral 3½ fingers; dorsal fingertips of lateral 3½ fingers (thumb, index, middle and half of ring finger) MOTOR SUPPLY. This fracture-dislocation, produced by a blow to the tip of the thumb, was described in 1881 by Edward Hallaran Bennett on the basis of his anatomical studies some 14 years before the discovery of x-rays. Each arises from the metacarpal shaft of the digit that it adducts (see fig. Figure 11-1 The position of the hand at rest.

Surg Radiol Anat 21(2):115–118, Sinnatamby CS (2011) Last’s anatomy, 12th edn. The extensor tendons have been omitted from both drawings. PLoS One 10(8):e0136477. 11-8), i.e., flexion at the metacarpophalangeal joints by the interossei and extension at the interphalangeal joints by the lumbricals.

Figure 11-15 Testing finger movements. Part of the flexor digitorum profundus in the arm flexes the pinky finger and ring finger. Churchill Livingstone Elsevier, China, Sraj SA, Moussallem CD, Stafford JB (2009) Cubital tunnel syndrome presenting with carpal tunnel symptoms: clinical evidence for sensory ulnar-to-Median Nerve communication. B, Dorsal view with the hood removed. This site needs JavaScript to work properly. These variations may be explained by the often under-recognized anastomoses that exist in the hand, such as the motor Riche–Cannieu Anastomosis. 11-10 Apart from claw hand, what motor deficits would be expected in ulnar nerve palsy? J Morphol Sci 29(1):23–26, Ferrari GP, Gilbert A (1991) Superficial Anastomosis on the palm of the hand between the ulnar and median nerves. The position of the wrist joint is indicated approximately by a line connecting the styloid processes of the radius and ulna. BMJ Case Rep. doi:10.1136/bcr-2013-008601, Rowntree T (1949) Anomalous innervation of the hand muscles. Severe instances are usually treated by excision of the aponeurosis. The extensor expansion, or dorsal aponeurosis. PubMed 

Arch Physiol 37:502–522, Gupta S, Michelsen-Jost H (2012) Anatomy and function of the thenar muscles. The "position of rest," resulting from merely intrinsic muscular tone, is assumed by the inactive hand (see fig.

The muscles of the hand are innervated by the radial, median, and ulnar nerves from the brach… 11-1 When the hand has to be immobilized, in which position should it be placed? doi:10.4021/jmc576w, Gruber W (1870) Ueber die Verbindung des Nervus medianus mit dem Nervus ulnaris am Unterame des Menschen um der Saugethiere.

Lower, If the metacarpophalangeal joint is stabilized as shown, flexion at the proximal interphalangeal joint (flexor superficialis) can be tested. The median nerve is one of the five main nerves originating from the brachial plexus and provides motor and sensory innervation to parts of the forearm and hand. Hand Clin 28(1):13–17. Although the central compartment is one space proximally, it is subdivided distally by a large number of sagittal septa. doi:10.1007/s00276-014-1416-1, Sulaiman S, Soames R, Lamb C (2015) Ulnar nerve cutaneous distribution in the palm: application to surgery of the hand. The radial artery leaves the forearm by curving dorsally to enter the anatomical snuffbox (see fig. This position includes slight wrist extension (30-45 degrees), flexion (70-90 degrees) at the metacarpophalangeal joints and near full extension at the interphalangeal joints. The muscles of the hand can be subdivided into two groups: the extrinsic and intrinsic muscle groups.

C, Medial view. He has interests in medical education, quality improvement and emergency/sports medicine. The short muscles of the little finger (see fig. the median nerve tends to supply the thenar muscles, and the ulnar nerve most of the other short muscles of the hand.

J Hand Surg 5:26–29, Felippe MM, Telles FL, Soares ACL, Felippe M (2012) Anastomosis between median nerve and ulnar nerve in the forearm. Some of these variations are associated significant clinical consequences. Among the intercarpal joints, the most important is the midcarpal joint, formed between the proximal and distal rows of the carpus, exclusive of the pisiform (fig. The ulnar artery enters the hand anterior to the flexor retinaculum, on the lateral side of the pisiform. Sensory: Test the dorsal webspace between the thumb and index finger; Median (C5-T1): Motor: Recurrent motor branch of the median nerve: Have the patient attempt opposition (bringing the thumb tip across to the small finger tip) volume 40, pages259–269(2018)Cite this article. (See, for example, F. Bojsen-Mol1er and L. Schmidt, J. The traditionally taught innervation of the hand is also found to be highly variable.

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