Palmar surface of the hand: deep structures. Topographic anatomy of the fingers Topography of the back and palmar surface of the hand

The topography of the hand is best viewed in two planes - anterior (palmar) and posterior (dorsal).

1. Front surface (Fig. 1). The palm is made up of three parts:

The central or proper palm (1), where the flexor tendons, blood vessels and nerves are located, is delimited by two transverse folds: the distal palmar fold (2) lies above the three medial metacarpophalangeal joints, and the middle palmar fold (3) outside passes over the metacarpophalangeal joint of the index finger;

A fleshy bulge on the outer side near the base of the first finger is the eminence of the thumb (4), delimited medially by the proximal palmar fold (5) (also known as the opposing thumb fold), where the tenar muscles or own muscles of the thumb are located; at the proximal apex of this protrusion, one can palpate a solid bony protrusion - the tubercle of the navicular bone (6);

Medially located elevation of the fifth finger (7), less pronounced than the tenar elevation, where the hypothenar muscles are located, that is, the own muscles of the little finger; Proximally, a firm bony protrusion of the pisiform bone (8) can be palpated, where the tendon of the flexor carpi ulnaris is attached.

Proximal to the palm is the wrist joint, which includes the midcarpal and radiocarpal joints, here you can see the carpal fold (9). Inward from the radial artery (11), where the pulse is usually counted, lies the attachment of the long palmar muscle (10). The wrist flexor retinaculum, located transversely, connects this area to the proximal part of the palm.

The fingers on the front surface are delimited from the palm by a finger-palmar fold (12), which lies 10–15 mm proximal to the metacarpophalangeal joints. The long fingers are separated from each other by II, III and IV interdigital spaces (13), which are deeper on the back of the hand than on the palmar. The proximal interphalangeal fold (14) is double. It is located somewhat proximal to the distal interphalangeal joint and separates the first phalanx (15) from the second (16). The distal interphalangeal fold (17) is single, it is located somewhat distal to the distal interphalangeal joint and delimits the ball of the finger (18), that is, the palmar surface of the terminal phalanx. The thumb, located at the base of the outer edge of the hand, is separated from it by a wide and deep interdigital space (19). Between it and the eminence are two finger-palm folds (20), located in the area of ​​the metacarpophalangeal joint of the first finger. The proximal phalanx (21) is separated from the ball of the finger (22), that is, from the palmar surface of the distal phalanx, by the interphalangeal fold (23), which lies distal to the interphalangeal joint.

2. The dorsal or posterior surface of the hand (Fig. 2) consists of two zones, namely the dorsum of the hand itself and the dorsum of the fingers.

The back of the hand is covered with thin, movable skin, in which there is a venous plexus that provides blood flow from the hand and fingers. The skin on the back of the hand is lifted by the extensor tendons (24). The dorsal surface of the hand ends distally with dense rounded metacarpal heads (25) and interdigital spaces (26), which are quite deep here.

Medially, the ulnar side of the hand (27) is lined with the adductor muscle of the fifth finger. On the outside (Fig. 3) is the first interdigital space (19). On the border between the wrist joint and the thumb, there is a slightly concave anatomical snuffbox (28), delimited by the tendons of the long abductor and short extensor of the first finger (29) and the tendon of the long extensor (30). In its depths are the styloid process of the radius, the trapezometacarpal joint (31) and the radial artery. The tendons converge on the dorsal surface of the I metacarpal bone (32) at the level of the metacarpophalangeal joint of the thumb (33).

Along the inner edge of the rear of the hand, one can see (only when pronating) a hard and rounded protrusion of the distal articular end of the ulna (34).

On the back surface of the fingers are proximal interphalangeal folds (35), lying directly above the interphalangeal joints. On the distal phalanges there are nails delimited by the periungual margins (37). The space between the nail and the distal interphalangeal fold covers the base of the nail (38).

Functionally, the brush can be divided into three components (Fig. 4):

The thumb (I), which participates in most of the functions of the hand due to its ability to oppose,

Index and middle fingers (II), which help the thumb to perform thin grips, that is, two-finger or triparts plucked grips,

The ring finger and little finger (III), which, together with the rest of the hand, are essential for making secure grasps of the handles of working tools from the ulnar side.

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brush area- distal free upper limb. It consists of three parts: the wrist, metacarpus and fingers.

wrist area separated from the forearm by a circular line drawn one transverse finger above the styloid process of the radius. The border with the palm is a line two transverse fingers below the styloid process of the radius (corresponding to the distal transverse fold of the wrist). Vertical lines running through the styloid process of the radius and ulna separate the anterior region of the wrist from the posterior region.

borders pasterns are: proximal - circular line, two transverse fingers below the styloid process of the radius; distally - finger folds and heads of metacarpal bones. The anterior surface of the pastern is called palmar region (palm), rear - rear of the cyst.

Layered structure of the anterior region of the wrist

Leather thin, mobile. Three transverse skin folds are visible at the level of the styloid processes. The middle fold serves as a projection line of the joint space of the wrist joint. The skin is innervated by the terminal branches of the lateral and medial cutaneous nerves of the forearm. Subcutaneous tissue loose, moderately developed.

own fascia in the anterior region of the wrist, it is represented by a thickened distal forearm fascia. At the lateral edge of the pisiform bone, as a result of the splitting of its own fascia, a ulnar nerve canal (ulnar canal of the wrist), Guyon Canal. It contains the ulnar neurovascular bundle. The ulnar artery, which is part of the bundle, and the veins accompanying it lie superficially and on the lateral side relatively ulnar nerve. After exiting the canal, the ulnar nerve divides into superficial and deep branches. Under its own fascia on the ulnar side is the tendon of the ulnar flexor of the wrist (attached to the pisiform bone and the base of the 5th metacarpal bone), and along the midline of the region are palmar branch median nerve and tendon long palmar muscle, passing to the hand in the palmar aponeurosis.

Retainer flexor muscles- a powerful ligament, consisting of strong transverse fibrous fibers, which are attached to the scaphoid and trapezoid bones on the radial side, and to the pisiform and hamate bones on the ulnar side. In the midline with the ligament, the own fascia and the tendon of the long palmar muscle grow together. Between the retinaculum of the flexor muscles and the bones of the wrist is formed canal (tunnel) of the wrist, through which the median nerve and tendons of the flexor muscles of the fingers pass, covered with synovial sheaths. The medial part of the tunnel is occupied by the tendons of the superficial and deep flexors of the fingers. On the lateral side of them is the tendon of the long flexor of the thumb, and more superficially - the median nerve.

The tendon of the long flexor of the thumb is enclosed in the synovial sheath of the same name. Its proximal blind end is located in the Pirogov-Paron space, rising 2 cm above the retinaculum of the flexor muscles. passing through the carpal tunnel, flexor thumb tendon sheath lies in the thenar region between the heads of the short flexor of the thumb and ends at the base of the distal phalanx of the first finger. The superficial and deep flexor tendons of the fingers are located in common flexor tendon sheath. The proximal end of this sheath rises 3-4 cm above the retinaculum of the flexor muscles, and the distal end along the course of the tendons reaches the level of the middle of the metacarpal bones. Along the tendons leading to the 5th finger, the common sheath reaches the base of its distal phalanx. In 10% of cases, the common sheath of the flexor tendons and the sheath of the tendon of the long flexor of the thumb communicate with each other, which explains the possibility of the formation of the so-called cross (K-shaped) phlegmon during inflammation of one of them. All sheaths are not closed from the lateral side. In this place, blood vessels approach the tendons.

The bundles of fibrous fibers that make up the retainer of the flexor muscles in the lateral part of the wrist are stratified and form a small fibrous canal-radius wrist channel. It contains a tendon flexor carpi radialis surrounded by the synovial sheath.

The bone basis of the region is wrist bones lying in two rows:

• proximal (from the radial side to the ulna) - the scaphoid, lunate, trihedral and pisiform bones;
• distal - trapezium, trapezius, capitate and hamate bones.

Surgical anatomy of the fingers. Technique of opening paronychia, subcutaneous panaritium and tendovaginitis. Amputation and disarticulation of fingers.

Skeleton: distal, middle, proximal phalanges.

joints: metacarpophalangeal and interphalangeal.

muscles: flexors and extensors in the form of tendons, separately the muscles of the elevation of the 1st and 5th fingers. The tendon sheaths of the 1st and 5th fingers are longer, which makes it possible for pus to spread into the Pirogov-Paron space.

Each finger has 4 arteries.

Innervation according to the UMRU type.

The flexors of the fingers have different tendon attachments to the phalanges of the fingers.

Paronychia: based on the localization, wedge-shaped, U-shaped and paired lateral incisions are used on the dorsal surface of the nail phalanx. It is necessary to open up to the unaffected elbow bed.

Subcutaneous felon: oval, arcuate, linear-lateral cuts. Necrotic areas are excised, revealing a purulent focus throughout with subcutaneous tissue directly above the zone of purulent tissue fusion.

With tendovaginitis along the lateral surface of the 1st or 5th fingers to their proximal end of the eminence. When flowing into the Pirogov space, an incision is made from the side of the forearm according to Canavelle.

Amputation: the flap is opened from the palmar side, and the scar remains on the back. The incision is made from the dorsal surface to the palmar, after dissection of the bone and joint, they are cut off from the palmar flap.

Exarticulation: when isolating the fingers, a single-flap method is used so that the scar, if possible, is located on the non-working surface: for the 3rd and 4th it is the back surface, for the 2nd it is the ulnar and back, for the 1st it is the back and the radius.

Surgical anatomy of the brachial plexus, its divisions, branches. Innervation of the skin and group innervation of the muscles of the upper limb. Operative access to the main nerves of the upper limb. Operations on nerves: nerve suture, neurolysis.

The brachial plexus is formed by branches of the four lower cervical, part of the anterior branch from the 4th and 1st thoracic branches of the s/m nerves. 3 trunks are formed: upper, lower, middle. After exiting the interstitial space, they are divided into supraclavicular and subclavian parts, in which they are divided into medial, lateral, and posterior bundles.

From the lateral bundle: the musculocutaneous nerve and the lat-I leg of the median nerve.

From the medial bundle: medial thoracic, medial root of the median nerve, ulnar, medial cutaneous nerve of the shoulder and forearm.

From the posterior bundle: subscapular nerve, thoracic, radial, axillary.

From supraclavicular: long thoracic nerve.

Radial - all extensors of the forearm, ulnar - all flexors on the shoulder according to the UMRU type, musculocutaneous - anterior pectoral muscle, posterior group of cutaneous nerves of the shoulder.

Operative accesses along the projection lines in the neurovascular bundles.

The radial nerve stands out on the opposite side of the forearm from the ulnar nerve: on the shoulder along the edge of the latissimus dorsi, then obliquely and downward from the medial groove of the biceps. Ulna from the condyle to the pisiform bone and next to a. brachialis, median also in the middle of the forearm; axillary - along the posterior edge of the deltoid muscle or from the axillary region behind the neurovascular bundle to the subscapularis muscle.

Nerve suture:

Accurate comparison of the excised bundles without traumatization. The edges are sutured at the time of Planned XO in order to create favorable conditions for healing.

Epineural suture: suturing of the epineurium with a comparison of the perineurium and trunk fibers using interrupted sutures is indicated for damage to the digital nerves or after excision of the parietal neuroma.

Perineural suture: restoration of the nerve by suturing the perineurium, optimal conditions are created for nerve regeneration, the threads are applied separately to each bundle, the restoration begins with deep-lying posterior bundles.

Neurolysis: an operation aimed at freeing the nerve from cicatricial adhesions that cause its infringement, after blunt injury or infringement or fracture of the bone. Excised within healthy tissues under a microscope while maintaining the integrity of the bundles.

Topography of the gluteal region. Surgical anatomy of neurovascular bundles and cellular spaces. Ways of distribution of hematomas and purulent processes. Incisions for phlegmon of the gluteal region.

Borders: Bounded by the iliac crest, gluteal fold, line joining the anterior iliac spine to the greater trochanter, sacrum, and coccyx.

Landmarks: anterior and posterior superior ischial spines, iliac crest, sacrum, coccyx, ischial tuberosity, greater trochanter of femur.

Layered anatomy: the skin is thick, dense, with a large number of sebaceous and polotny glands, fat deposits are well expressed, there is a subcutaneous trochanteric bursa, the upper nerve of the buttock, the lower nerve of the buttock, the middle nerves of the buttock, branches of the upper and lower gluteal arteries and veins. Next is the superficial fascia. The gluteal fascia forms the sheath of the gluteus maximus muscle. Further, the gluteus maximus muscle and the tensor fascia lata, a layer of fatty tissue communicates with the middle floor of the small pelvis, the ischiorectal fossa, the posterior fascial bed of the thigh (a bag of the gluteus maximus muscle is located above the large trochanter). Further, the gluteus medius, piriformis, gemellus superior, tendon of the obturator internus, gemini inferior and quadratus, gluteus minimus and obturator externus, iliac and ischia.

Blood supply: from the branches of the internal and external iliac arteries, from the internal iliac, superior and inferior gluteal arteries, obturator, femoral arteries.

Innervation: superior and inferior gluteal nerves, sciatic nerve, posterior cutaneous nerve.

Ways of distribution of hematomas and purulent processes: in the saddle-rectal fossa, the middle floor of the small pelvis and with the posterior fascial bed of the thigh.

Incisions for phlegmon:

Along the gluteal fold;

Along the lateral edge of the gluteus maximus muscle and the tensor fascia lata.

Surgical anatomy of the fingers. Technique of opening paronychia, subcutaneous panaritium and tendovaginitis. Amputation and disarticulation of fingers. - concept and types. Classification and features of the category "Surgical anatomy of the fingers. Technique of opening paronychia, subcutaneous felon and tendovaginitis. Amputation and exarticulation of the fingers." 2017, 2018.

The manual introduces the methodology for conducting basic operations, considers the relative position of organs and tissues in various parts of the body. For students of higher medical educational institutions.

LECTURE 11. TOPOGRAPHICAL ANATOMY OF THE HAND REGION

1. Borders. The hand is delimited from the forearm by a line drawn 2 cm above the styloid process of the ray. Areas of the hand - wrist, metacarpus, fingers. Radial and ulnar edges, it is divided into palmar and dorsal regions. External landmarks- styloid processes of the ulna and radius, skin folds of the wrist, furrows and folds of the palm, palmo-finger and interdigital folds, heads of metacarpal bones and phalanges of the fingers.

2. Palmar region. Three transverse skin folds are visible at the level of the styloid processes. At the ulnar edge of the palm proximally - pisiform bone. Lateral to it is the neurovascular bundle. The middle wrist fold serves as a projection line of the wrist joint. Between the two elevations formed by the muscles of the I and V fingers is triangular palmar cavity, apex proximally. It corresponds to the location of the palmar aponeurosis. The proximal third of the longitudinal skin fold delimiting thenar from the palmar aponeurosis - Canavela restricted area, here passes the motor branch of the muscles of the median nerve of the first finger. Opposite the interdigital folds are three elevations - pads. They match commissural foramina of the palmar aponeurosis. The synovial sheaths of the tendons of the II-IV fingers are projected into the grooves between the pads. The transverse folds of the palmar surface of the fingers correspond to the ligaments that strengthen the fibrous canals of the flexor tendons. Leather thick, immobile. In the subcutaneous layer, at the base of the hypothenar, there are transverse bundles of the short palmar muscle. At the lateral edge of the wrist passes r. palmaris superficialis a. radialis. Fascia is a thickening of the distal fascia of the forearm. Near the pisiform bone, the fascia forms a canal through which the neurovascular bundle passes. The flexor tendon retinaculum is a ligament consisting of transverse fibers thrown in the form of a bridge over the bony edges of the palmar surface of the wrist. The ligament is stretched between the navicular and trapezoid bones on the one hand, and the pisiform and hamate bones on the other. This place is formed carpal tunnel, through which the flexor tendons and the median nerve pass. The anterior wall of the canal is the superficial sheet of the ligament, the posterior wall is the carpal bones and the deep sheet of the ligament. Own fascia of the palm is expressed differently. The muscles of the eminences of the I and V fingers are covered with a thin plate, and on the palmar cavity it is represented by a palmar aponeurosis.

The longitudinal fibers of the aponeurosis are combined into 4 bundles, heading to the bases of the II and V fingers. The spaces between the longitudinal and transverse bundles of the aponeurosis are called commissural openings. From the longitudinal bundles of the aponeurosis to the deep transverse metacarpal ligaments, proximally under the aponeurosis, there are vertical tendon septa, forming fibrotic intercarpal canals, where the worm-like muscles are located. There are two fascial intermuscular septa: lateral and medial. Lateral- goes vertically deep, then, horizontally forming a torsion in the form of a fold, and is attached to the V metacarpal bone. Medial- attaches to the fifth metacarpal bone. Fascial beds - lateral, medial and medial. Lateral, in front - own fascia; behind - deep fascia and I metacarpal bone; medially - lateral intermuscular septum; laterally - due to the attachment of its own fascia to the I metacarpal bone. It contains the muscles of the first finger - m. abductor pollicis brevis, m.flexor pollicis longus, m.flexor pollicis brevis, m. opponens pollicis, m. adductor pollicis . Medial, in front and medially - own fascia, attached to the V metacarpal bone, behind - by the V metacarpal bone, laterally - by the medial intermuscular septum. It contains the muscles of the V finger: m. abductor digiti minimi, m. opponens digiti minimi, m.flexor digiti minimi brevis. Median: in front - palmar aponeurosis, behind - deep fascia, laterally and medially - intermuscular septa of the same name. The flexor tendons are located in it, dividing it into two slots: subaponeurotic and subtendonous, in which there are superficial and deep arterial arches. The flexor tendons of the II-V fingers are located in the common synovial sheath from Pirogov's space to the middle of the metacarpal bones. The tendon of the fifth finger lies further in a separate synovial sheath and ends at the base of the distal phalanx.

3. The area of ​​the back of the hand: In the area of ​​​​the wrist at the radial edge of the hand, when the first finger is abducted, a fossa is visible - anatomical snuffbox. It projects the radial artery and the navicular bone. At the apex of the styloid process of the ulna, a branch of the ulnar nerve is projected, innervating the skin of the V, IV and ulnar side of the III finger. At the apex of the styloid process of the ray, branches of the radial nerve are projected, innervating I, II and the radial side of the III finger. Projection wrist joint goes along an arc, the top of which is 1 cm above the line connecting the tops of the styloid processes. The projection of the gaps of the interphalangeal joints is determined in the position of full flexion of the fingers by 2–3 mm. below the bulges of the heads of the phalanges. The articular gap of the metacarpophalangeal joints corresponds to a line located at 8–10 mm. below the heads of the metacarpal bones. The skin is thin and mobile. The subcutaneous tissue is loose, it contains superficial vessels and nerves. The fascia at the level of the wrist joint is thickened and forms extensor retinaculum. Below it is 6 bone fibrous canals. The canals contain the extensor tendons of the hand and fingers. In the area of ​​​​the metacarpus between the proper and deep fascia is subaponeurotic space where the extensor tendons of the fingers are located. On the back of the fingers extensor tendon consists of three parts, the middle one is attached to the base of the middle one, and the two lateral ones are attached to the base of the distal phalanx. Above the proximal phalanx is an aponeurotic extension, into the edges of which the tendons of the vermiform and interosseous muscles are woven. The interphalangeal joints are reinforced with lateral ligaments.

In the area of ​​the wrist joint there are three channels, resulting from the presence here retinaculum flexorum.

Throwing in the form of a bridge from eminentia carpi ulnaris to eminentia carpi radialis, it turns a gutter between the named hills, sulcus carpi, into the channel canalis carpalis, and bifurcating into the radial and ulnar sides, forms, respectively canalis carpi radialis and canalis carpi unlaris.

In the cubital canal are the ulnar nerve and vessels, which continue here from the sulcus ulnaris of the forearm. V canalis carpi radialis lies tendon m. flexor carpi radialis, surrounded by a synovial sheath.

Finally, in canalis carpalis are 2 separate synovial sheaths: 1) for tendons mm. flexores digitorum superficialis et profundus and 2) for tendon m. flexoris pollicis longus.

First vag. synovialis communis mm. flexorum represents a medially located voluminous sac covering 8 tendons of the deep and superficial flexors of the fingers. At the top, it protrudes 1–2 cm proximal to the retinaculum flexorum, and at the bottom it reaches the middle of the palm. Only on the side of the little finger does it continue along the tendons of the long muscles that flex it, surrounding them and reaching with them the base of the distal phalanx of the fifth finger.

Second vagina, vag. tendinis m. flexoris pollicis longi, located laterally, it represents a long and narrow canal, in which the tendon of the long flexor of the thumb is enclosed. At the top, the vagina also protrudes 1-2 cm proximal to the retinaculum flexorum, and below it continues along the tendon to the base of the distal phalanx of the first finger.

Rest 3 fingers have separate vaginas, vag. synoviales tendinum digitorum (manus) covering the flexor tendons of the corresponding finger. These sheaths extend from the line of the metacarpophalangeal articulation to the base of the nail phalanges. Consequently, II-IV fingers on the palmar side have isolated sheaths for the tendons of their common flexors, and on the segment corresponding to the distal halves of the metacarpal bones, they are completely devoid of them.

Vagina synovialis communis mm. flexorum, covering the tendons of the V finger, at the same time does not surround the tendons of the II-IV fingers on all sides; it is believed that it forms three protrusions, one of which is located in front of the tendons of the superficial flexors, the other is between them and the tendons of the deep flexor, and the third is behind these tendons. Thus, the ulnar synovial sheath is a true synovial sheath only for the tendons of the fifth finger.

The tendon sheaths on the palmar side of the fingers are covered with a dense fibrous plate, which, adhering to the scallops along the edges of the phalanges, forms a bone-fibrous canal on each finger, surrounding the tendons along with their sheath. The fibrous walls of the canal are very dense in the area of ​​the bodies of the phalangeal bones, where they form transverse thickenings, pars annularis vaginae fibrosae.

In the area of ​​​​the joints, they are much weaker and are reinforced by obliquely intersecting connective tissue bundles, pars cruciformis vaginae fibrosae. The tendons inside the vagina are connected to their walls through thin mesentery, mesotendineum, which carry blood vessels and nerves.

Training video anatomy of the synovial sheaths of the tendons of the hand