PRINCIPAL ARTERY OF THUMB:

An artery with origin in the radial artery, with distribution to the palmar surface and sides of the thumb, and with anastomoses to the arteries on the dorsum of the thumb.

- Tendon Sheath Anatomy: - A1 pulley: spans the MP joint, approximately 8 mm in width; - note that the FPB inserts just proximal to this pulley and the adductor pollicis inserts distal to the A1 pulley; - oblique pulley: located over the mid aspect of the phalanx, approximately 10 mm in width; - note that the adductor pollicis partially inserts into the oblique pulley; - A2 pulley located at the most distal aspect of the proximal phalanx, and is 9 mm in width; - it may partially span the thumb IP joint; - Zone 1 Flexor Tendon Injuries: - in thumb, zone 1 extends from tip of finger to just distal to IP joint; - contains, oblique and A2 pulleys; - of these, the oblique is more important, but either can be sacrificed if the other remains intact; - most tendon injuries of thumb occur at level of IP crease, which is near point of the FPL insertion; - exposure: - skin laceration needs to be extended both proximally and distally; - flexor tendon sheath is "Z" step cut so that edge of the resected sheath lies about 1 cm beyond excursion of thickened area of sutured tendon; - tendon retrieval: - first, note that FPL tendon lacerations often retract into the thenar area or wrist; - unlike the fingers, the FPL often lacks a vinculum and does not have a lumbrical, and therefore the tendon is free to retract; - when there is tendon retraction, the tendon must be retrieved at the wrist; - second, note that the FPL tendon sheath is narrow in the thenar region, and therefore, passage of the tendon thru the sheath can be frustrating; - it is important to avoid "scuffing" of the tendon edge as it is pulled thru the tunnel; - pass a curved tendon grasper retrograde thru the FPL tendon, and insert a core grasping suture into the free edge of the tendon; - the tendon grasper is then used to pull the suture back thru the tunnel; - delayed reconstruction: FPL Advancement and Pull Thru: - Zone 2 Flexor Tendon Injuries: - over thenar eminence, injuries to FPL tendon are likely to occur in conjunction w/ injuries to thenar muscles & recurrent branch of median nerve; - Tendon Transfers: - the following musculotendinous units have adequate exursion (muscle amplitude), but lack tension strength based on cross sectional area: EPL, EIP, PL; - muscles that replace strength and excursion are the following - FDS to the long and ring fingers, ECU, and ECRL;

- origin: - tuberosity of the scaphoid and the ridge of trapezium; - another slip originates from the transverse carpal ligament; - insertion: lateral surface of the base of the proximal phalanx of thumb; - action: abdcution and medial rotation of the metacarpal of the thumb; - synergists: abductor pollicis longus, EPL;

- nerve supply: median nerve, C8, T1; - Discussion: - although opposition is result of coordinate function of all long and short muscles that act on the thumb, APB is most important single muscle that takes part in this complex movement; - it rotates internally and abducts the thumb away from index metacarpal, internally rotates andabducts the proximal phalanx of thumb on its metacarpal, and assists EPL in extending IP joint of the thumb; - in the cases of carpal tunnel syndrome, it is APB which atrophies, and if this atrophy is severe the thumb cannot be pronated;

Extensor Pollicis Brevis

- Anatomy: - origin: - posterior side at the distal end of the body of both the ulna and radius near their middle; - insertion: - posterior surface of the base of the proximal phalanx of thumb; - action: - extends proximal phalanx of the thumb; continued action extends and assists abduction of the 1st metacarpal; - synergists: APL, EPL; - nerve:: PIN branch of deep radial nerve, C6, C7; - Discussion: - annular ligament that restrains abductor pollicis longus & EPB over radius is directly over radial tubercle; - this area may be involved in DeQuervain's tenosynovitis;

A simplified technique to correct hyperextension deformity of the metacarpophalangeal joint of the thumb.

Extensor Pollicis Longus

- See: Extensor Pollicis Longus Rupture: - Anatomy: - origin: posterior surface of the middle 1/3 of the ulna & interosseous membrane; - insertion: posterior surface of the base of the distal phalanx of thumb; - action: extends the distal phalanx of the thumb; continued action, extends proximal phalanx and adducts the 1st metacarpal; - nerve: PIN branch of deep radial nerve, C6, C7, & C8; - Tunnel III: - on ulnar side of Lister's Tubercle contains EPL , which defines ulnar border of anatomic snuff box; - EPL tendon takes 45 deg turn around Lister's tubercle; - then after passing over ECRL & ECRB tendons of tunnel I, it continues along its course to the thumb; - note: that the "cross over" between the EPL and the ECR tendons can become involved in a cross over syndrome, just distal to the extensor retinaculum; - Exam: - palpate length of tendon, look for any signs of rupture; - ask pt to place hand flat on table, & lift only thumb off surface; - w/ rupture, patient will be unable to raise the thumb in line w/ the second metacarpal;

Extensor pollicis longus opposition transfer. Effects of extensor pollicis longus transposition and extensor indicis proprius transfer to extensor pollicis longus on thumb mechanics.

Flexor Pollicis Brevis

- Origin: - superficial head: distal border of the flexor retinaculum; - greater multangular bone tuberosity of the trapezium bone deep head; - trapezoid and capitate bones; - Insertion: base of the proximal phalanx of the thumb; - Action: - flexes proximal phalanx of the thumb; continued action flexes first metacarpal and rotates it medially; - Synergists: FPL, adductor pollicis; - Nerve supply: superficial head: Median, C8, T1 deep head: Ulnar, C8, T1; - Discussion: - FPB is on volar surface of metacarpal and under abductor brevis; - one head of the flexor brevis originates from volar carpla ligament and in the region of the Flexor Carpi Radialis tendon; - other originates from trapezium and from capitate tendon that inserts into radial sesamoid & radial tubercle of proximal phalanx; - this muscle also attaches to an expansion into the extensor mech. and assists in extending the distal phalanx of the thumb;

Flexor Pollicis Longus

- See: - Forearm Flexors - FPL Rupture: - Thumb Tendon Injuries: - Anatomy: - origin: - anterior surface of middle 1/2 of radius; adjacent interosseous membrane and a slip from coronoid process of the ulna or medial epicondyle of humerus; - FPL tendon rests between two sesamoid bones, & tendon is covered by fibrous canal, annular ligament, which is responsible for trigger thumb mechanism; - insertion: palmer surface of the base of the distal phalanx of the thumb; - action: - flexes the interphalangeal joint of the thumb; continued action, flexes the MP and CMC articulations; - thumb functions most independently (of the digits), but in 10 % of population tip of thumb & index finger function simultaneously; - synergists: FPB, adductor pollicis; - nerve supply: median (AIN branch), C8, T1 > C6, C7; - Pathologic Anomolous Anatomy: - FPL may have accessory proximal head, which and cause contracture of thumb secondary to elbow injuries as accessory head attaches to medial epicondyle of the humeus; - muscle belly may be involved w/ in isolated anterior interosseous compression syndromes, in localized ischemic contracture, or in lacerations;

Ulnar Nerve
- See - Cubitbal Tunnel Syndrome - Differential Dx: Ulnar Nerve Dysfunction: - Martin Gruber Anastomosis - Ulnar Nerve Blocks: - Ulnar Nerve in Condylar Fractures: - Anatomy: - brachial plexus: - C8 and T1 nerve roots give rise to the medial cord which in turn, forms the ulnar nerve; - ulnar nerve passes distally, just medial to axillary artery, pierces medial intermuscular septum halfway down the arm, passes back over medial head of triceps, around posterior aspect of medial epicondyle, & enters forearm between two heads of FCU; - anatomy and sites of compression in the cubital tunnel: - just below elbow, it sends branches to FCU & ulnar half of FDP; - it passes down forearm under FCU , & then into Guyon's canal; - dorsal sensory branch: - the nerve emerges from the medial border of the FCU about 5 cm proximal to the pisiform; - supplies dorsoulnar aspect of the hand and the ulnar 1 1/2 fingers; - terminal branches in the hand: - guyon's canal: - superficial cutaneous branch to ulnar portion of palm & volar surfaces of ulnar 1 1/2 fingers, - deep motor branch passes adjacent to hook of hamate; - deep branch, innervating hypothenar muscles & third & fourth lumbricales, adductor pollicis, all interossei, & deep head of FPB; - references: - The lateral root of the ulnar nerve. - General Orthopaedics: The Anatomy of the Distal Ulnar Tunnel. - The Dorsal Branch of the Ulnar Nerve: An Anatomic Study. - Palmar cutaneous branch of the ulnar nerve. WD. Engber and JG Gmeiner. J. Hand. Surg. Vol 5. 1980.

p 26. - Distribution pattern of the deep branch of the ulnar nerve in the hypothenar eminence. - A Neural Loop of the Deep Motor Branch of the Ulnar Nerve: An Anatomic Study. Rogers-MR. Bergfield-TG. Aulicino-PL. J Hand Surg. 1991. 16A. pp 269-271. - A variation in the path of the deep motor branch of the ulnar nerve at the wrist. R. Lassa and MM Shrewsbury. JBJS. Vol 57-A. 1975. p 990.

- Trauma to Ulnar Nerve: (see: nerve repair) - combined lesions of the median and ulnar nerves: - high ulnar nerve lesions - low ulnar nerve injury - division of ulnar nerve at wrist results in paralysis of all small muscles of hand except first & second lumbricales & most of thenar muscles; - paralysis of adductor pollicis produces Froment's sign; - when grasping piece of paper between thumb and index finger, FPL fires (IP joint flexion) since adductor does not work; - if ulnar nerve is divided below mid-forearm, ulnar claw hand is produced; (low ulnar nerve lesions); - w/ this lesion, 4th & 5th fingers are hyperextended at MP joints by long extensors but flexed at interphalangeal joints; - this posture is sometimes called hand of benediction; - if ulnar nerve lesion is above midforearm, clawing of ulnar two fingers does not occur, because extrinsic muscles producing IP joint flexion are also denervated (see high ulnar nerve lesion); - in complete claw hand, produced by low lesion of median nerve & ulnar nerves, MP joints are extended & interphalangeal joints flexed by still-functional extrinsics; - references: - Repair of median and ulnar nerves. Primary suture is best. - Epiperineurium-fascial stitches along the stumps of a transected nerve. An additional method for closing the gap in the nerve trunk. - Experience with the free vascularized ulnar nerve graft in repair of supraclavicular lesions of the brachial plexus. - The results of secondary microsurgical repair of ulnar nerve injury.

- Cubital Tunnel Syndrome: - w/ severe cases of cubital tunnnel syndrome, there will be decreased two point sensory distribution of ulnar nerve as well as muscle weakness and/or muscle wasting of intrinsic innervated by the ulnar nerve; - clinical findings include positive Froment's test, wasting of first dorsal interosseous muscle, inability to cross index and middle fingers, & clawing of ring & small fingers;

- Entrapment of Ulnar Nerve at Wrist: - clinical findings: - positive Tinel's sign on percussion over ulnar nerve at guyon's canal; - positive Phalen's test w/ paresthesias in ring & small fingers - it will not show loss of sensation over dorsoulnar aspect of hand; - increase in two point discrimination; - changes with nerve conduction studies and electromyograms; - pts may also develop claw hand - diff dx: - ganglion (produces motor and sensory deficit) - frx (frx of 5th CMC or hook of hamate) - anomalous muscles; - anomalous muscle belly at level of the wrist, which includes, palmaris brevis profundus, ADM, FDM, and FCU; - thrombosis of ulnar artery or SPA; - synovitis; - treatment: - w/ compression of ulnar & median nerves at wrist, ulnar nerve symptoms may improve with carpal tunnel surgery alone;

Median Nerve

- Carpal Tunnel Syndrome - Combined Lesions of the Median and Ulnar Nerves: - High Median Nerve Lesions - Low Median Nerve Lesions - Median Nerve Block - Median Nerve Injuries at the Wrist - Martin Gruber Anastomosis - Anatomy: - roots: C6, C7, C8, and T1 (? C5) - brachial plexus - cords: - lateral cord: contributes mainly sensory axons from C6 and C7 - medial cord: provides main bulk of motor input through C8 and T1 - position in the arm: - has no branches in arm; - crosses brachial artery from lateral to medial in the arm, then passes over brachialis; - median nerve is parallel and anterior to the medial intermuscular septum; - entrapment of median nerve at the elbow and forearm: - supracondylar process: - small hook of bone 5 cm above medial epicondyle; - may form accessory origin for pronator teres, thru ligament of Struthers; - median nerve may be displaced medially and compressed by these structures; - compression is worsened w/ extension and supination; - present in approximately 1% of individuals of European descent - references: - Entrapment neuropathy of the median nerve at the ligament of Struthers T. Bilge et al. Neurosurgery. Vol 27. 1990. p 787-789. - Median nerve compression by the supracondylar process: A case report. MM al-Qattan and JB Husband. J. Hand. Surg. Vol 16. 1991. p 101-103. - lacertus fibrosis: - this is a site of potential compression; - is tightened w/ pronation of forearm as bicipital tuberosity of the radius passes posteriorly; - ref: Acute compression of the median nerve at the elbow by the lacertus fibrosus. - pronator teres compression syndrome: - nerve enters forearm between 2 heads of pronator teres (beneath the superficial-humeral) which is a site of potential compression; - passing superficial to the FDP and beneath FDS, it supplies all muscles on front of forearm except FCU & ulnar half of FDP; - nerve may be compressed by the fibrous arch of FDS; - anterior interosseous branch - position in distal forearm and in the carpal tunnel: - see: carpal tunnel syndrome and surgical decompression and median nerve injuries at the wrist - palmar cutaneous branch: - runs between & deep to FCR & palmaris longus into carpal tunnel; - nerve lies superficial to the tendons of the FDP and FPL; - FDS tendons lie lateral to the nerve; - motor branch: - variations: - martin gruber anastomosis - bifid (high division) of median nerve: associated w/ a median artery; - references: - Variations of the median nerve in the carpal canal. - Anatomical variations of the median nerve in the carpal tunnel. U. Lanz. J. Hand Surg. Vol 2. 1997. p 44-53. - Exam: - signs of a median nerve lesion include weak pronation of the forearm, weak flexion & radial deviation of wrist, with thenar atrophy & inability to oppose or flex the thumb; - sensory distribution includes thumb, radial 2 1/2 fingers, and corresponding portion of palm. - w/ intact nerve, thumb can be pronated, lining up nails at or near 180 deg; - w/ median nerve palsy, thumb can't be pronated & nail is < 100 deg;

Hand

In the hand, the median nerve supplies motor innervation to the 1st and 2nd lumbrical muscles. It also supplies the muscles of the thenar eminence by a recurrent thenar branch. The rest of the intrinsic muscles of the hand are supplied by the ulnar nerve. The median nerve innervates the skin of the palmar side of the thumb, the index and middle finger, half the ring finger, and the nail bed of these fingers. The lateral part of the palm is supplied by the palmar cutaneous branch of the median nerve, which leaves the nerve proximal to the wrist creases. This palmar cutaneous branch travels in a separate fascial groove adjacent to the flexor carpi radialis and then superficial to the flexor retinaculum. It is therefore spared in carpal tunnel syndrome. The muscles of the hand supplied by the median nerve can be remembered using the mnemonic, "LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis.[2]

Radial Artery
- See: Vascular Problems of the Wrist and Hand:

- Radial Artery in the Forearm: - in the mid forearm, the radial artery lies beneath the brachioradialis - here the brachioradialis recieves arterial branches just below elbow; - Radial Artery in Wrist: - at wrist ulnar artery terminates in superficial palmar arch that provides most of the blood supply to the fingers; - radial artery terminates in deep palmar arch, which provides blood to thumb & thenar side of index finger & gives rise to collat. branches; - radial artery becomes deep palmar as it enters palm between two segments of the first dorsal interosseous muscle; - it passes into palm between oblique & transverse heads of adductor pollicis & then forms deep palmar arch by anastomosing w/ deep branch of ulnar artery; - in the web space, the artery divides into princeps pollicis and radialis indicis; - radialis indicis: - this runs along the radial side of index finger; - princeps pollicis artery branches from the radial artery before it is covered by the oblique head of the adductor pollicis muscle; - it runs along volar aspect of adductor muscle between FPB and tendon of the FPL;

- at the thumb, it divides into two palmar digital branches; - at level of MP joint, it branches into two volar arteries of thumb; - ulnar artery is prime contributor to superficial arch which also receives a branch of superficial branch of the radial artery; - Puncture of Artery: - radial artery is frequently cannulated percutaneously for ABG monitoring and for continuous pressure monitoring; - incidence of radial artery thrombosis after cannulation is approx, 10-20%, but fortunately, the condition is asymptomatic in most pts, because of collateral circulation from the ulnar artery; - because, > 20% of pts have incomplete palmar arch, these patients are at risk for thrombosis of the radial artery; - initial treatment is w/ Fogarty catheter (size 2 Fr); - allen test should be performed in all patients prior to radial artery cannulation; - alternative is to place a pulse oximeter to the thumb and to compress the radial artery; - if there is an incomplete superficial palmar arch, then the pulse ox will not register on the thumb (w/ radial a. compression); - references: - Radial artery cannulation. A prospective study in patients undergoing cardiothoracic surgery. - Radial artery cannulation: influence of catheter size and material on arterial occlusion. - Aspirin pretreatment prevents post-cannulation radial-artery thrombosis. Bedford RF. Ashford TP. Anesthesiology. [JC:4sg 51(2):176-8, 1979 Aug. - Long-term radial artery cannulation: effects on subsequent vessel function. - Radial arterial function following percutaneous cannulation with 18- and 20-gauge catheters. - Acute exacerbation of carpal tunnel syndrome after radial artery cannulation. - Wrist hyperextension leads to median nerve conduction block: implications for intra-arterial catheter placement. - Should an Allen test be performed before radial artery cannulation?

Ulnar Artery
- See: - Vascular Problems of the Wrist and Hand: - Ulnar Artery in Forearm: - about 1 inch below the antecubital fossa, brachial artery divides into radial & ulnar arteries, w/ latter being larger; - paired venae comitantes accompany both radial & ulnar arteries; - interosseous branch: - about 1 inch below origin of ulnar artery, common interosseous artery arises & divides into anterior or volar branch and posterior or dorsal branch; - anterior branch runs down forearm in the midline on interosseous membrane; - posterior branch runs down forearm on posterior side; - in forearm, the ulnar artery is deeper than radial artery; - it passes under the arch of the FDS, lying between the medial edges of the FDS and FDP, and just deep to the FCU; - as it passes down the forearm lying just lateral (deep) to the ulnar nerve; - dorsal branch of the ulnar artery: - originates between 2-4 cm proximal to the pisiform, which passes medially beneath the FCU tendon; - artery runs dorsally and ulnarly; - artery divides into an ascending and descending branch along the inferior surface of the FCU; - ascending artery provides vascularization on the ulnar side of the forearm for a length of 9-20 cm and 510 cm wide; - at wrist ulnar artery terminates in superficial palmar arch that provides most of the blood supply to the fingers; - Ulnar Artery in Hand: - radial and ulnar arteries terminate by dividing into superficial and deep branches;

- line drawn across the palm at level of distal border of fully abducted thumb marks the approximate locatation of the superficial arch; - deep arch is a finger's breath superficial; - pulsation of the ulnar artery can usually be felt just lateral to the pisiform bone; - immediately distal to this point, artery divides into its larger branch which forms most of superficial arch & smaller branch which forms lesser part of deep palmar; - superficial arch is much larger & important than the deep arch - just proximal to pisiform bone the ulnar artery gives off volar and dorsal carpal branches which unite w/ volar and dorsal branches of radial artery to form arterial wristlet about carpal bones;