Anatomy Coaching Program:

A. Upper Extremity

I. Bones of the upper extremity: 64 (includes the clavicle and scapula )

Clavicle ( collar bone )=2
Scapula ( shoulder blade = 2 )
Humerus= 2
Radius= 2
Ulna= 2
Carpal bones= 16 (arranged in two rows of four (lateral to medial): Scaphoid, Lunate, Triquetrum,
Pisiform, Trapezium, Trapezoid, Capitate, and Hamate (mnemonic device: Sandra Likes To Pat
Tom's Two Cold Hands). (Trapezium precedes trapezoid alphabetically.)
Metacarpals= 10
Phalanges= 28

II. Joints and Ligaments

1. Acromioclavicular joint:
a. synovial plane joint that allows a gliding movement when the scapula rotates and is
reinforced by the coracoclavicular ligament
2. Sternoclavicular joint:
a. double synovial plane (gliding) joint
b. allows elevation and depression, protraction and retraction, and circumduction of the
shoulder
3. Shoulder (glenohumeral) joint:
a. synovial ball-and-socket joint
b. allows abduction and adduction, flexion and extension, and circumduction and rotation.
c. innervated by the axillary, suprascapular, and lateral pectoral nerves.
d. receives blood from branches of the suprascapular, anterior and posterior humeral
circumflex, and scapular circumflex arteries.
4. Elbow joint
a. forms a synovial hinge joint
b. innervated by the musculocutaneous, median, radial, and ulnar nerves.
c. receives blood from the anastomosis formed by branches of the brachial artery and
recurrent branches of the radial and ulnar arteries.
5. Proximal radioulnar joint
a. forms a synovial pivot joint in which the head of the radius articulates with the radial
notch of the ulna
b. allows pronation and supination.
6. Distal radioulnar joint-
a. forms a synovial pivot joint between the head of the ulna and the ulnar notch of the radius
b. allows pronation and supination.
7. Wrist (radiocarpal) joint-
a. a synovial condylar joint formed superiorly by the radius and the articular disk and
inferiorly by the proximal row of carpal bones (scaphoid, lunate, and rarely triquetrum),
exclusive of the pisiform
b. allows flexion and extension, abduction and adduction, and circumduction
8. Midcarpal joint:

a. forms a synovial plane joint between the proximal and distal rows of carpal bones
b. allows gliding and sliding movements.
c. a compound articulation:
- laterally, the scaphoid articulates with the trapezium and
trapezoid, forming a plane
joint
- medially, the scaphoid, lunate, and triquetrum articulate with the capitate and hamate,
forming a condylar (ellipsoidal type) joint.
9. Carpometacarpal joints:
a. synovial saddle (sellar) joints between the carpal bone (trapezium) and the first
metacarpal bone
b. allows flexion and extension, abduction and adduction, and circumduction.
c. also form plane joints between the carpal bones and the medial four metacarpal bones,
allowing a simple gliding movement
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 10. Metacarpophalangeal joints:
a. condyloid joints , supported by a palmar ligament and two collateral ligaments
b. allow flexion and extension and abduction and adduction.
11. Interphalangeal joints:
a. hinge joints , supported by a palmar ligament and two collateral ligaments
b. allow flexion and extension.

III. Clinical Correlates to bones and joints

1. Fracture of the clavicle:
a. results from a fall on the shoulder or outstretched hand
b. occurs in the junction of the middle and lateral thirds of the clavicle
c. may cause injury to the brachial plexus (lower trunk
2. Fracture of the greater tuberosity:
a. occurs by direct trauma or by violent contractions of the supraspinatus muscle.
3. Fracture of the lesser tuberosity:
a. accompanies posterior dislocation of the shoulder joint, and the bone fragment has the
insertion of the subscapularis tendon
4. Fracture of the surgical neck:
a. may injure the axillary nerve and the posterior humeral circumflex artery as they pass
through the quadrangular space
5. Fracture of the shaft:
a. may injure the radial nerve and deep brachial artery in the spiral groove.
6. Supracondylar fracture:
a. a fracture of the distal end of the humerus; it is common in children and occurs when the
child falls on the outstretched hand with the elbow partially flexed
b. may injure the median nerve.
7. Fracture of the medial epicondyle:
a. may damage the ulnar nerve
8. Colles' fracture of the wrist:
a. a fracture of the lower end of the radius in which the distal fragment is displaced (tilted)
posteriorly, producing a characteristic bump described as
dinner (silver) fork deformity
because the forearm and wrist resemble the shape of a dinner fork
9. Smith's fracture:
a. a reverse Colles' fracture, the distal fragment is displaced anteriorly
10. Fracture of the scaphoid:
a. occurs after a fall on the outstretched hand and may damage the radial artery
11. Fracture of the hamate:
a. may injure the ulnar nerve and artery because they are in close proximity to the hook of
the hamate
12. Bennett's fracture:
a. a fracture of the base of the metacarpal of the thumb.
13. Boxer's fracture:
a. a fracture of the necks of the second and third metacarpals, seen in professional boxers,
and typically of the fifth metacarpal in unskilled boxers.
14. Guyon's canal syndrome:
a. an entrapment of the ulnar nerve in the Guyon's canal
15. Dislocation of the acromioclavicular joint:
a. results from a fall on the shoulder with the impact taken by the acromion or from a fall on
the outstretched arm
16. Dislocation (subluxation) of the shoulder joint:
a. occurs usually in the anteroinferior direction due to lack of support by tendons of the
rotator cuff
b. may damage the axillary nerve and the posterior humeral circumflex vessels
17. Rotator (musculotendinous) cuff:
a. formed by the tendons of the supraspinatus, infraspinatus, teres minor, and sub-scapularis
(SITS)
b. fuses with the joint capsule; and provides mobility.

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IV. Cutaneous Nerves, Superficial Veins, and Lymphatics
1. Cutaneous Nerves:
A. Supraclavicular nerve
a. rises from the cervical plexus (C3, C4)
b. innervates the skin over the upper pectoral, deltoid, and outer trapezius areas.
B. Medial brachial cutaneous nerve:
a. arises from the medial cord of the brachial plexus and innervates the medial side of
the arm
C. Medial antebrachial cutaneous nerve
a. arises from the medial cord of the brachial plexus and innervates the medial side of
the forearm.
D. Lateral brachial cutaneous nerve
a. arises from the axillary nerve and innervates the lateral side of the arm.
E. Lateral antebrachial cutaneous nerve
a. arises from the musculocutaneous nerve and innervates the lateral side of the forearm.
F. Posterior brachial and antebrachial cutaneous nerves
a. arise from the radial nerve and innervate the posterior sides of the arm and forearm
G. Intercostobrachial nerve
a. lateral cutaneous branch of the second intercostal nerve
b. emerges from the second intercostal space by piercing the intercostal and serratus
anterior muscles.
c. may communicate with the medial brachial cutaneous nerve.

2. Superficial Veins of the Upper Limb

A. Cephalic vein
a. begins as a radial continuation of the dorsal venous network, runs on the lateral side
b. often connected with the basilic vein by the median cubital vein in front of the elbow.
c. pierces the costocoracoid membrane of the clavipectoral fascia and empties into the
axillary vein
B. Basilic vein
a. arises from the dorsal venous arch of the hand
b. accompanies the medial antebrachial cutaneous nerve on the posteromedial surface of
the forearm and passes anterior to the medial epicondyle.
c. pierces the deep fascia of the arm and joins the twobrachial veins , the venae
comitantes of the brachial artery, to form the axillary vein at the lower border of the teres
major muscle.
C. Median cubital vein
a. connects the cephalic vein to the basilic vein over the cubital fossa.
b. lies superficial to thebicipital aponeurosis
D. Median antebrachial vein
a. arises in the palmar venous network
b. ascends on the front of the forearm
c. terminates in the median cubital or the basilic vein.
E. Dorsal venous network
a. receives dorsal digital veins by means of dorsal metacarpal veins.

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V. Superficial Lymphatics and Axillary Lymph Nodes
A. Lymphatics of the finger
a. drain into the plexus on the dorsum and palm of the hand.
B. Medial group of lymphatic vessels
a. accompanies the basilic vein
C. Lateral group of lymphatic vessels
a. accompanies the cephalic vein and drains into the lateral axillary nodes and into the
deltopectoral (infraclavicular) node, which then drain into the apical nodes.
D. Axillary lymph nodes
1. Central nodes
a. lie near the base of the axilla between the lateral thoracic and subscapular veins;
receive lymph from the lateral, pectoral, and posterior groups of nodes; and drain into the
apical nodes.
2. Lateral (brachial) nodes
a. lie posteromedial to the axillary veins, receive lymph from the upper limb, and drain
into the central nodes.
3. Subscapular (posterior) nodes
a. lie along the subscapular vein, receive lymph from the posterior thoracic wall and the
posterior aspect of the shoulder, and drain into the central nodes.
4. Pectoral (anterior) nodes
a. lie along the inferolateral border of the pectoralis minor muscle
b. receive lymph from the anterior and lateral thoracic walls, including the breast
drain into the central nodes.
5. Apical nodes
a. lie at the apex of the axilla medial to the axillary vein and above the upper border of
the pectoralis minor muscle, receive lymph from all of the other axillary nodes (and
occasionally from the breast), and drain into the subclavian trunks.

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V. A. The Breast
a. consists of mammary gland tissue, fibrous and fatty tissue, blood and lymph vessels, and nerve
b. forms the floor of the axilla attached to the suspensory ligament of the axilla that forms the
hollow of the armpit by traction when the arm is abducted.
c. extends from the second to sixth ribs and from the sternum to the midaxillary line, divided into
the upper and lower lateral and medial quadrants.
d. has mammary glands, which lie in the superficial fascia.
e. supported by the suspensory ligaments (Cooper's ligaments)
f. has a nipple: lies at the level of the fourth intercostal space and areola

g. Blood supply:
1. medial mammary branches of the anterior perforating branches of the internal thoracic
artery
2. lateral mammary branches of the lateral thoracic artery
3. pectoral branches of the thoracoacromial trunk
4. lateral cutaneous branches of the posterior intercostal arteries
h. Innervation:
1. anterior and lateral cutaneous branches of the second to sixth intercostal nerves

B. The Mammary gland

a. a modified sweat gland located in the fatty superficial fascia
b. has axillary tail , a small part of the mammary gland that extends superolaterally
through the deep fascia to lie in the axilla
c. retromammary space: allows the breast some degree of
movement over the pectoralis
major muscle
d. has 15 to 20 lobes of glandular tissue,
e. each lobe opens by a lactiferous duct onto the tip of the nipple
f. each duct enlarges to form a lactiferous sinus: serves as a reservoir for milk during
lactation

C. Clinical correlates
1. Mammography
a. a radiographic examination of the breast to screen for benign and malignant tumors and
cysts
b. plays a part in early detection of breast cancers
2. Breast cancer:
a. occurs in the upper lateral quadrant (about 60% of cases)
b. forms a palpable mass in advanced stages
c. attaches to Cooper's ligaments, and produces shortening of the ligaments, causing
depression or dimpling of the overlying skin
d. inverted nipple: shortening of the lactiferous ducts
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 3. Radical mastectomy:
a. extensive surgical removal of the breast, including the pectoralis major and minor
muscles, axillary lymph node sand fascia, and part of the thoracic wall
b. may injure the long thoracic and thoracodorsal nerves
c. may cause postoperative swelling (edema) of the upper limb as a result of lymphatic
obstruction
4. Modified radical mastectomy:
a. involves excision of the entire breast and axillary lymph nodes, with preservation of
the pectoralis major and minor muscles
5. Lumpectomy (tylectomy):
a. surgical excision of only the palpable mass in carcinoma of the breast.

VI. Axilla:
A. Boundaries:
Medial wall: upper ribs and their intercostal muscles and serratus anterior muscle.
Lateral wall: humerus.

Posterior wall: subscapularis, teres major, and latissimus dorsi muscles.

Anterior wall: pectoralis major and pectoralis minor muscles.
Base: axillary fascia.

Apex: interval between the clavicle, scapula, and first rib
B. Contents: axillary vasculature, branches of the brachial plexus, lymph nodes, and areolar tissue

VII. The Brachial Plexus

a. formed by the ventral primary rami of the lower four cervical nerves and the first thoracic
nerve (C5- T1)
b. has roots that pass between the scalenus anterior and medius muscles.
c. enclosed with the axillary artery and vein in the axillary sheath, formed by a prolongation of the
prevertebral fascia.

d. Subdivisions:
A. Branches from the roots
1. Dorsal scapular nerve (C5):
a. pierces the scalenus medius muscle
b. innervates the rhomboids and frequently the levator scapulae muscles
2. Long thoracic nerve (C5- C7)
a. supplies the serratus anterior muscle

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 B. Branches from the upper trunk
1. Suprascapular nerve (C5- C6)
a. supplies the supraspinatus muscle and the shoulder joint and the infraspinatus muscle.
2. Nerve to subclavius (C5)
a. supplies the subclavius muscle and the sternoclavicular joint
3. Branches from the lateral cord
1. Lateral pectoral nerve (C5- C7):
a. innervates the pectoralis major muscle primarily and the pectoralis minor muscle
2. Musculocutaneous nirve (C5- C7)
a. pierces the coracobrachialis muscle and innervates these three muscles -
coracobrachialis muscle, biceps brachii and brachialis muscles
4. Branches from the medial cord
1. Medial pectoral nerve (C8-T1)
a. supplies the pectoralis minor muscle and the pectoralis major muscle.
2. Medial brachial cutaneous nerve (C8- T1)
a. innervates the skin on the medial side of the arm.
3. Medial antebrachial cutaneous nerve (C8-T1)
a. innervates the skin on the medial side of the forearm
4. Ulnar nerve (C7-T1)
a. runs down the medial aspect of the arm but does not branch in the brachium
5. Branches from the medial and lateral cords:
1. Median nerve (C5-T1)
a. formed by heads from both the medial and lateral cords
6. Branches from the posterior cord
1. Upper subscapular nerve (C5-C6)
a. innervates the upper portion of the subscapularis muscle.
2. Thoracodorsal nerve (C7- C8)
a. Runs behind the axillary artery
accompanies the thoracodorsal artery to enter the latissimus dorsi muscle
3. Lower subscapular nerve (C5- C6)
a. innervates the lower part of the subscapularis and teres major muscles
4. Axillary nerve (C5- C6)
a. innervates the deltoid and teres minor muscles
b. gives rise to the lateral brachial cutaneous nerve
5. Radial nerve (C5-T1)
a. the largest branch of the brachial plexus
b. occupies the musculospiral groove on the back of the humerus with the profunda
brachii artery.

e. Clinical Correlates:
1. Injury to the long thoracic nerve:
Cause: stab wound or during radical mastectomy or thoracic surgery
a. results in paralysis of the serratus anterior muscle and inability to elevate the arm
above the horizontal.
b. produces awinged scapula in which the vertebral (medial) border of the scapula
protrudes away from the thorax
2. Injury to the posterior cord:
a. Cause by the pressure of the crosspiece of a crutch, resulting in paralysis of the arm
called crutch palsy
c. results in loss in function of the extensors of the arm, forearm, and hand and produces
a wrist drop.
3. Injury to the axillary nerve:
a. caused by a fracture of the surgical neck of the humerus or inferior dislocation of the
humerus
b. results in weakness of lateral rotation and abduction of the arm (the supraspinatus can
abduct the arm but not to a horizontal level)
4. Injury to the radial nerve:
a. caused by a fracture of the midshaft of the humerus.
b. results in loss of function in the extensors of the forearm, hand, metacarpals, and
phalanges
c. results in loss of wrist extension, leading to wrist drop , and produces a weakness of
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 5. Injury to the musculocutaneous nerve:
a. results in weakness of supination (biceps) and forearm flexion (brachialis and biceps).
6. Injury to the median nerve:
Caused: by a supracondylar fracture of the humerus or a compression in the carpal tunnel.
a. results in loss of pronation, opposition of the thumb, and flexion of the lateral two
interphalangeal joints and impairment of the medial two interphalangeal joints.
b. also produces a characteristic flattening of the thenar eminence, often referred to asape
hand.
7. Injury to the ulnar nerve:
a. caused by a fracture of the medial epicondyle and results in a claw hand , in which the
ring and little fingers are hyperextended at the
metacarpophalangeal joints and flexed at
the interphalangeal joints
b. results in loss of abduction and adduction of the fingers and flexion of the
metacarpophalangeal joints because of paralysis of the palmar and dorsal interossei
muscles and the medial two lumbricals
8. Upper trunk injury (Erb-Duchenne paralysis or Erb palsy):
a. caused by a birth injury during a breech delivery or a violent displacement of the head
from the shoulder such as might result from a fall from a motorcycle or horse
b. results in a loss of abduction, flexion, and lateral rotation of the arm, producing a waiter's
tip hand , in which the arm tends to lie in medial rotation resulting from paralysis of
lateral rotator muscles.
9. Lower trunk injury (Klumpke's paralysis):
a. caused during a difficult breech delivery (birth palsy or obstetric paralysis), by a cervical
rib (cervical rib syndrome), or by abnormal insertion or spasm of the anterior and middle
scalene muscles (scalene syndrome)
b. the injury causes a claw hand

VIII. Axillary Artery

a. central structure of the axilla
b. extends from the outer border of the first rib to the inferior border of the teres major muscle,
where it becomes the brachial artery
c. axillary artery is bordered on its medial side by the axillary vein
d. Branches:
1. Superior or supreme thoracic artery
a. supplies the intercostal muscles in the first and second anterior intercostal spaces and
adjacent muscles.
2. Thoracoacromial artery
a. a short trunk from the first or second part of the axillary artery and has pectoral,
clavicular, acromial, and deltoid branches.
b. pierces the costocoracoid membrane (or clavipectoral fascia)
3. Lateral thoracic artery
a. runs along the lateral border of the pectoralis minor muscle
b. supplies the pectoralis major, pectoralis minor, and serratus anterior muscles and the
axillary lymph nodes
c.gives rise to lateral mammary branches
4. Subscapular artery:
a. largest branch of the axillary artery
b. divides into the thoracodorsal and circumflex scapular arteries.

Parts of the Axillary artery:

a. pectoralis minor muscle crosses in front of the axillary artery and divides it into three parts:
1. First Part of the Axillary Artery
a. extends from the lateral border of the first rib to the upper border of the pectoralis minor
2. Second Part of the Axillary Artery
a. lies behind the pectoralis minor muscle
3. Third Part of the Axillary Artery
a. extends from the lower border of the pectoralis minor to the lower border of the teres
major

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IX. Axillary vein
a. formed at the lower border of the teres major muscle by the union of the venae comitantes of the
brachial artery and the basilic vein
b. runs upward on the medial side of the axillary artery and ends at the lateral border of the first rib
by becoming the subclavian vein

X. Muscles

Muscles of the Pectoral Region

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XI. Triangle of Auscultation
a. Boundaries:
the upper border of the latissimus dorsi muscle, the lateral border of the trapezius muscle, and the
medial border of the scapula; its floor is formed by the rhomboid major muscle.
b. the site at whichbreathing sounds are heard most clearly

XII. Arterial anastomoses around scapular

a. occur between three groups of arteries:
(a) suprascapular, descending scapular, and circumflex scapular arteries
(b) acromial and posterior humeral circumflex arteries
(c) descending scapular and posterior intercostal arteries.

XIII. The Arm

1. Brachial intermuscular septa: enclosed the arm
a. consist of medial and lateral intermuscular septa: divide the arm into the anterior
compartment (flexor compartment ) and the posterior compartment (extensor compartment ).

2. Contents of the Anterior Fascial Compartment of the Upper Arm ( Flexor )

Muscles: Biceps brachii, coracobrachialis, and brachialis
Blood supply: Brachial artery
Nerve supply to the muscles: Musculocutaneous nerve
Structures passing through the compartment: Musculocutaneous, median, and ulnar nerves;
brachial artery and basilic vein.
The radial nerve is present in the lower part of the compartment.

3. Contents of the Posterior Fascial Compartment of the Upper Arm ( Extensor )

Muscle: The three heads of the triceps muscle
Nerve supply to the muscle: Radial nerve
Blood supply: Profunda brachii and ulnar collateral arteries
Structures passing through the compartment: Radial nerve and ulnar nerve

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XIV. Arteries of the Upper Extremity

XV. Cubital fossa

a. V-shaped interval on the anterior aspect of the elbow
b. bounded laterally by the brachioradialis muscle and medially by the pronator teres muscle
c. has a lower end where the brachial artery divides into the radial and ulnar arteries, with a fascial
roof strengthened by the bicipital aponeurosis.
d. Contains (from lateral to medial) the R adial nerve, B iceps tendon, B rachial artery, and M edian
nerve (mnemonic device:R onB eatsB adM an).
XVI. Clinical Correlates
1. Tennis elbow (lateral epicondylitis):
a. Caused: chronic inflammation or irritation of the origin (tendon) of the extensor muscles of the
forearm from the lateral epicondyle of the humerus as a result of unusual or repetitive strain
b. a painful condition and common in tennis players and violinists
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 2. Golfer's elbow (medial epicondylitis):
a. a painful condition caused by a small tear or an inflammation or irritation in the origin of the
flexor muscles of the forearm from the medial epicondyle
3. Cubital tunnel syndrome:
a. results from compression on the ulnar nerve in the cubital tunnel behind the medial epicondyle
(funny bone ) causing numbness and tingling in the ring and little fingers

XVII. The Forearm

A. Contents of the Anterior Fascial Compartment of the Forearm
Muscles:
1. superficial group, consisting of: the pronator teres, the flexor carpi radialis, the palmaris longus,
and the flexor carpi ulnaris
2. intermediate group consisting of the flexor digitorum superficialis
3. deep group consisting of the flexor pollicis longus, the flexor digitorum profundus, and the
pronator quadratus
Blood supply to the muscles: Ulnar and radial arteries
Nerves: Median nerve, Anterior Interosseous Nerve, Ulnar nerve

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B. Contents of the Lateral Fascial Compartment of the Forearm
The lateral fascial compartment may be regarded as part of the posterior fascial compartment.
Muscles:
1. Brachioradialis and extensor carpi radialis longus
Blood supply: Radial and brachial arteries
Nerve supply to the muscles: Radial nerve

C. Contents of the Posterior Fascial Compartment of the Forearm

Muscles:
1. superficial group includes the extensor carpi radialis brevis, extensor digitorum, extensor digiti
minimi, extensor carpi ulnaris, and anconeus.
These muscles possess a common tendon of origin, which is attached to the lateral epicondyle of
the humerus
2. deep group includes the supinator, abductor pollicis longus, extensor pollicis brevis, extensor
pollicis longus, and extensor indicis.
Blood supply: Posterior and anterior interosseous arteries
Nerve supply to the muscles: Deep branch of the radial nerve

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XVIII. The Region of the Wrist
a. the carpal Tunnel
b. the carpus is deeply concave on its anterior surface and forms a bony gutter.
c. the gutter is converted into a tunnel by the flexor retinaculum

Structures on the Anterior Aspect of the Wrist

The structures that pass superficial to the flexor retinaculum from medial to lateral:
1. Flexor carpi ulnaris tendon, ending on the pisiform bone. (This tendon does not actually cross the
flexor retinaculum but is included for the sake of completeness.)
2. Ulnar nerve lies lateral to the pisiform bone.
3. Ulnar artery lies lateral to the ulnar nerve.
4. Palmar cutaneous branch of the ulnar nerve
5. Palmaris longus tendon (if present), passing to its insertion into the flexor retinaculum and the
palmar aponeurosis
6. Palmar cutaneous branch of the median nerve

The following structures pass beneath the flexor retinaculum from medial to lateral:
1. Flexor digitorum superficialis tendons and, posterior to these, the tendons of the flexor digitorum
profundus; both groups of tendons share a common synovial sheath.
2. Median nerve
3. Flexor pollicis longus tendon surrounded by a synovial sheath

Structures on the Posterior Aspect of the Wrist

The following structures pass superficial to the extensor retinaculum from medial to lateral:
1. Dorsal (posterior) cutaneous branch of the ulnar nerve
2. Basilic vein
3. Cephalic vein
4. Superficial branch of the radial nerve
The following structures pass beneath the extensor retinaculum from medial to lateral:
1. Extensor carpi ulnaris tendon, which grooves the posterior aspect of the head of the ulna
2. Extensor digiti minimi tendon is situated posterior to the distal radioulnar joint.
3. Extensor digitorum and extensor indicis tendons share a common synovial sheath and are
situated on the lateral part of the posterior surface of the radius.
4. Extensor pollicis longus tendon winds around the medial side of the dorsal tubercle of the
radius.
5. Extensor carpi radialis longus and brevis tendons share a common synovial sheath and are
situated on the lateral part of the posterior surface of the radius.

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 Abductor pollicis longus and the extensor pollicis brevis tendons have separate synovial sheaths but
share a common compartment.

XIX. The Hand

The Palmar Aponeurosis
a. triangular and occupies the central area of the palm
b. the apex of the palmar aponeurosis is attached to the distal border of the flexor retinaculum and
receives the insertion of the palmaris longus tendon
c. the base of the aponeurosis divides at the bases of the fingers into four slips.
d. Function: to give firm attachment to the overlying skin and so improve the grip and to protect the
underlying tendons
e. Muscles of the Hand

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XX. Arteries of the Palm
1. Ulnar Artery
a. enters the hand anterior to the flexor retinaculum on the lateral side of the ulnar nerve and the
pisiform bone
b. gives off a deep branch and then continues into the palm as the superficial palmar arch.
c. superficial palmar arch is a direct continuation of the ulnar artery
d. Four digital arteries arise from the convexity of the arch and pass to the fingers
e. the deep branch of the ulnar artery arises in front of the flexor retinaculum
2. Radial Artery
a. deep palmar arch is a direct continuation of the radial artery

XXI. Nerves of the Palm

1. Median Nerve
a. enters the palm by passing behind the flexor retinaculum and through the carpal tunnel
2. Ulnar Nerve
a. enters the palm anterior to the flexor retinaculum alongside the lateral border of the pisiform

XXII. 1. Carpal Tunnel Syndrome

a. formed by the concave anterior surface of the carpal bones
b. closed by the flexor retinaculum, tightly packed with the long flexor tendons of the fingers, with
their surrounding synovial sheaths, and the median nerve
c. consists of a burning pain or pins and needles along the distribution of the median nerve to the
lateral three and a half fingers and weakness of the thenar muscles
d. produced by compression of the median nerve within the tunnel

2. Trigger Finger
a. a palpable and audible snapping when a patient is asked to flex and extend the fingers.
b. caused by the presence of a localized swelling of one of the long flexor tendons that catches
on a narrowing of the fibrous flexor sheath anterior to the metacarpophalangeal joint
3. Mallet Finger
a. avulsion of the insertion of one of the extensor tendons into the distal phalanges can occur if
the distal phalanx is forcibly flexed when the extensor tendon is taut.
b. the last 20° of active extension is lost, resulting in a condition known as mallet
4. Boutonnaire Deformity
a. avulsion of the central slip of the extensor tendon proximal to its insertion into the base of the
middle phalanx results in a characteristic deformity
b. results from flexing of the proximal interphalangeal joint and hyperextension of the distal
interphalangeal joint.
c. this injury can result from direct end-on trauma to the finger, direct trauma over the back of
the proximal interphalangeal joint, or laceration of the dorsum of the finger.

XXIII. The Dorsum of the Hand

1. Dorsal Venous Arch (or Network)
a. lies in the subcutaneous tissue proximal to the metacarpophalangeal joints
b. drains on the lateral side into the cephalic vein and, on the medial side, into the basilic vein

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