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1989; 69:1007-1013.PHYS THER.Christine A MoranAnatomy of the Hand

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Anatomy of the Hand

Theanatomy of thehand is efficientlyorganized to cany out a varietyofcomplex tasks. These tasks requirea combination of intricate movementsand finelycontrol led force production The shapeof thebony anatomy in conjunction withthearrangement of soft tissues contributes to the complex kinesiologyof thehand.Injury to any of these structurescan alter theoverall function of thehand andtherefore complicatethe therapeuticmanagement. The purpose of this article is toreview theanatomy of thehand with special emphasison structures that relatetomanagement of hand injuries. [Moron CA: Anatomyof thehand. Phys Ther69:1007-1013, 1989]K ey W ords: Anatomy; Hand; Hand injuries; Kinesiology/biomechanics, upperextremity; Upper extremity, hand andwrist.

Christine A M oran

The hand is a complex anatomicalsystem of dynamic and static structures. Very often the general clinician is wary of treating patients withhand injuries because of the hand'sanatomical and kinesiologicalcomplexity. These injuries are further complicated by traumatic orsurgical processes. The purpose ofthis article is to review the anatomyof the hand emphasizing importantstructures related to therapeuticmanagement.ArthrokinematicsF ingerThe carpometacarpal (CMC) jointsof the fingers are classified as planejoints with one degree of freedom.However, the fifth CMC joint isoften classified as a semisaddle jointwith conjunctional rotation.1 The

metacarpophalangeal (MCP) jointsare classified as ellipsoidal orcondylar joints with two degrees offreedom.1,2 Specifically, the metacarpal condylar surface is asymmetricalwith a greater sloping configurationof the radial shoulder than the ulnarshoulder.3 This articular configuration plays a role in ligamentous orientation and subsequent kinesiologyof the joint. Therefore, it is of functional importance in describing certain pathological conditions such asulnar drift.3The proximal interphalangeal (PIP)and distal interphalangeal (DIP)joints are both bicondylar with subsequently greater congruencybetween bony surfaces. They haveone degree of freedom.1,2 In addition, the axis of motion has anobliquity of 6 to 13 degrees in thecoronal plane because of the

unevenness of the condylar articulating surfaces at both PIP and DIPjoints.2-4 This divergence of the distal aspect of these joints is accentuated by the pull of the flexor digito-rum sublimus (FDS) tendons andallows for opposition with thethumb. This divergence of the interphalangeal (IP) joint is importantclinically when restoring motion viajoint mobilization techniques. Volargliding of the middle phalanxshould be accomplished with thiscoronal tilt added to the glidingmotion, thus more accurately stressing the capsular tissues.ThumbTheCMC joint of the thumb is a sellarjoint exhibiting two degrees of freedom with reciprocally convex-concavesurfaces allowing for the motions offlexion and extension (concave-convex), abduction and adduction(convex-concave), and conjunctionalrotation.1,2,5,6 The thumb MCP joint issimilar to the fingerMCP jointsarthrokinematically. The thumb IPjoint's articulating condyles also display an unevenness, resulting in anobliquity of the axis of motion of 5to10 degrees.

C M oran, MS, PT, is Director, T he Richmond Upper Extremity Center, 7113 Three Chopt Rd,Suite 203, Richmond, VA 23226, Assistant Clinical Professor, Department of Physical T herapy,School of A ll ied Health Professions, Medical Col lege of Virginia, Virginia Commonwealth University, PO Box 224, MCV Station, R ichmond, VA 23298-0024, and Adjunct Assistant Clinical Professor,Program in Physical T herapy, Old Dominion U niversity, Norfolk, VA 23508.Address correspondence to Ms Moran at The Richmond Upper Extremity Center, 7113 ThreeChopt Rd, Suite 203, Richmond, VA 23226 (USA).Physical Therapy/Volume 69, Number 12/December 1989 1007/15

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J oint CapsuleThe joint capsule is a fibrous structurecomposed of irregular, dense connective tissue that accepts stress and permits stretch in all directions of thatjoint's motion.2 Within the joint capsule is contained the synovial membrane from which synovial fluid isproduced for these joints. The jointcapsule of all the digital joints displaysspecific redundancies to accommodate for motion. Wise produced evidence for this configuration by demonstrating significant volar and dorsalredundancies in arthrograms of thedigital joints.7 Bojsen-Moller identif ieda large, thin capsule surrounding theCMC joint of the thumb.8 Kuczynskinoted that the joint surfaces could bedistracted 3 mm when supportingcapsular structures were removed.9During periods when the hand is immobilized for surgical or traumatic reasons, the finger joint capsule will adap-tively shorten in the immobilizedposition, preventing normal motion ofthe articular surfaces later. This configuration supports the clinical rationaleto stress this structure during treatment for improved joint mobility. Itwould appear that maximal length isnecessary for CMC joint rotation oropposition.Minami et al observed that the dorsalMCP joint capsule provides stabilityduring long-axis distraction and rotatory motions.11 Specifically, the volarcapsule of all finger joints is taut inextension, whereas the dorsal capsuleis taut in flexion.Volar PlateThe volar plate is a fibrocartilagousstructure that serves as a volar articulating surface, an attachment for ligaments, an additional confining structure for synovial fluid, and an inhibitorof dorsal dislocation during MCP jointextension.1,2,10,11 The volar-plate attachments at the MCP joint are capsularrather than bony, which permits hyper-extension. A similar volar-plate attachment is noted at the DIP joint level.The plate attachments are different atthe PIP joint level. Bowers et al identified a bony attachment of the PIP

Fig. 1. Palmar viewof dissectedhand showing transverse intermetacarpal ligament,whicharises from volar plate toattach to adjacent volar plate at level ofmetacarpalhead. (Reprinted withpermission from Guyot J , Atlas of HumanLimb Joints,New York,NY, Springer-Verlag New York Inc, 1981, p 104.)joint's volar plate that provides greaterjoint stability.12 In their analysis of jointruptures, they observed that the staticresistance to hyperextension is offeredby the lateral insertion of the volarplate-collateral ligament at the marginof the phalangeal condyle.L igamentsThere are important extracapsular andcapsular ligaments that support andstabilize the hand. The most important extracapsular ligament is thetransverse intermetacarpal ligament(TIML) (Fig. 1). It attaches to andcourses between volar plates at thelevel of the metacarpal heads alongthe entire width of the hand. Thesestructures, the TIML and the metacarpal heads, comprise the distal transverse arch.13 Full extensibility of thisligament is necessary for graspingactivities and prehensile activities.Zancolli noted that the extensibility ofthe TIML between the third andfourth MCP joints and between thefourth and fifth MCP joints is particu

larly important because the fourthand fi fth rays descend 5 to 7 mm withrespect to the third ray when makinga full fist.14 Therefore, if this mobilityis restricted because of traumatic scarring or "immobilization tissue shortening," function is greatly hampered.The capsular collateral ligaments of allfinger and thumb joints provideimportant joint stability. The MCP jointcollateral ligaments have been investigated in light of their probableinvolvement in the pathomechanics ofulnar drift.3 The radial and ulnar MCPjoint collateral ligaments are eccentrically placed, which allows for selective tautness and slackness throughouttheir range of movement (Fig. 2). Thisplacement also promotes the arthoki-nematic motions of roll and slide.1115The change in ligament length is dueto the prominent condylar shoulderthat the collateral ligaments must passover. In addition, Hakstian and Tubi-ana observed that the radial collateralligament is consistently longer thanthe ulnar collateral ligament.3 This

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Fig. 2. Schematic representation ofeccentric placement of metacarpophalangeal oint collateral ligamentsandcamlike configuration of metacarpalhead (P =flexor digitorumprofundus).(Reprintedwith permission.15)finding was reported as part of theiranatomical investigation of the etiology of ulnar drift. They noted that thetendency toward an ulnar-deviatedposition was due to ligament lengthand the slope differences of theradial and ulnar condylar shoulders.In addition, they observed that thegreatest stability at the MCP jointwas provided by the ligaments. Theyresected all supporting structuressequentially to produce this observation. This stability was alsoobserved by M inami et al.10 All ofthese data confirm the rationale ofmaintaining ligament length bysplinting the MCP joint in flexion.The MCP joint ligaments have dualattachmentsbony and glenoid(Fig. 3). Thus, the classical distinctionis noted: The fan or glenoid portionarises from the metacarpal head andattaches to the volar plate, and thecord or collateral portion arises fromthe metacarpal head and attaches tothe base of the phalanx.In contrast, the PIP and DIP joint collateral ligament attachments are completely bony (Fig. 4). Kuczynski

Fig. 3. Dissected view of inger showing bony and glenoid metacarpophalangealjoint collateral ligaments (indicated byarrows). (Reprinted withpermission from GuyotJ , Atlas of Human LimbJoints, NewYork,NY, Springer-Verlag New York Inc, 1981,p 106.)

Fig. 4- Dissected viewof finger showing collateral ligamentsofproximal and distalinterphalangeal oints. (Reprintedwith permission from Guyot ,Atlasof Human LimbJoints,NewYork,NY, Springer-Verlag New York Inc, 1981, p 103.)observed only bony attachments ofthe PIP joint collateral ligaments.16,17Shrewsbury and J ohnson noted thatthe two components of the DIP jointcollateral ligaments overlap by asmuch as one third.18The collateral l igaments of the PIP andDIP joints are concentrically placedand are of equal length.15-17 Thus, the

ligaments are maximally taut throughout the range of motion. In addition,the phalangeal articular surfaces aresquare and fairly regular in condylarprominence, adding to the consistentligament tautness. Kuczynski notes thatligament length can be maintained inextension, contradicting the clinicalnotion of splinting IP joints in slightflexion to maintain length.16,17

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The thumb CMC joint displays aunique configuration of ligaments:three capsular, one extracapsular.5,6,8,9They are the anterior oblique ligament, the dorsoradial ligament, theposterior oblique ligament, and theintermetacarpal ligament (Fig. 5). Thecapsular ligaments are oblique in orientation, suggesting the maximal support provided by these structuresoccurs during thumb rotation andpinch-prehensile activities. Pieronmethodically recorded the positionsthat caused maximal span of theseoblique ligaments.6 He observed thatthe dorsoradial position caused maximal span in 3 of the 4 ligaments(Fig. 6). Therefore, according to hisfindings, that joint position would bethe optimal splinting position to maintain l igament length. Eaton and Littlerobserved that the anterior obliqueligament provided stabilizing functionby stabilizing the volar beak of thefirst metacarpal.5The fourth ligament, which is extracapsular, is the intermetacarpal ligament, more commonly known asthe "Y" ligament.6,8 This ligamentarises from the volar aspect of thetrapezium and courses distallybetween the first and second metacarpals. It then bifurcates andattaches to the bases of those metacarpals. The Y ligament has a tethering function of keeping the firstmetacarpal on the trapezium.8 Thislack of congruency most often happens during thumb abduction andforceful key-pinch activities, andchanges in this ligament have notably affected thumb function, particularly in the rheumatoid thumb.Nerve-M uscle ArrangementMovements of the hand are accomplished by a combination of intrinsicand extrinsic musculature. Specifickinesiological reviews of muscle function are beyond the scope of this article. The reader is urged to consultother references for thisinformation.19-21The three peripheral nerves of theupper extremity (radial, median, andulnar) innervate the intrinsic and

Fig. 5. Ligamentsof thumbcarpometacarpal oint: (Top) Anterior view showinganterior oblique ligament (AOL) and intermetacarpal ligament (IML); (Bottom) posterior view showing dorsoradial ligament(DRL) and posterior oblique ligament (POL).(MI = firstmetacarpal;MII= secondmetacarpal; td = trapezoid; tm = trapezium;J C =joint capsule; APL = abductor pollicis longus.) (Reprintedwith permission.6)extrinsic muscles of the hand. Theforearm musculature are presented inGardner et al as distinct layers

(Fig. 7).22 This approach aids the clinician in palpation and muscle testingand will be used in this review.

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JL

D

KI

position of M Iulno-dorsalradio-dorsal

radio-volar

ulno-volarulnar

area of joint contactulno-dorsal quadrantdorso-radial quadrant

dorso-radial quadrantradio-volar quadrantulno-volar quadrantulno-volar quadrant

maximal span of ligaments1. anterior oblique ligament2. dorso-radial ligament (radial half)1. anterior oblique ligament2. dorso-radial ligament (ulnar half)3. posterior oblique ligament4. intermetacarpal ligament1. anterior oblique ligament2. posterior oblique ligament3. intermetacarpal ligament1. dorso-radial ligament2. anterior oblique ligament1. dorso-radial ligament2. anterior oblique ligament

Fig. 6. Maximal span of carpometacarpal oint ligaments (MI = irstmetacarpal).(Reprintedwith permission.6)At the volar wrist level, the tendonsassume a specific anatomical arrangement (Fig. 8). All volar tendons passthrough the carpal tunnel with theexception of the flexor carpi ulnaristendon as it attaches to the pisiformand the palmaris longus tendon,which passes superficial to the volarcarpal ligament. Usually, the palmarislongus tendon lies superficial to themedian nerve and, therefore, can beused as a landmark for palpation ofthe nerve. The volar carpal l igamentattaches to the tubercle of the scaphoid and the tubercle of the trapeziumradially and to the pisiform and hookof the hamate ulnarly to form the roofof the carpal tunnel. Within the carpaltunnel, passing laterally to medially,are the following structures: flexorcarpi radialis (FCR) tendon, flexorpollicis longus (FPL) tendon, mediannerve, FDS tendons, and flexor digito-rum profundus (FDP) tendons. Thearrangement of the finger flexor tendons as shown in Figure 8 is important to remember when evaluatingpartial wrist lacerations. In this type ofinjury, the FCR tendon, median nerve,and some or all of the FDS tendonscan be lacerated, leaving the FPL andFDP tendons intact because these tendons lie deep within the carpal tunnel. Clinically, the patient could dis

play inconsistent thumb and fingerflexor motions.The intrinsic muscles are categoricallypresented as the thenar musclegroup, the hypothenar muscle group,and the interosseous muscles. Thethenar muscle group is composed ofthe abductor pollicis brevis, flexorpollicis brevis, opponens pollicis, andadductor pollicis muscles. These muscles are primarily innervated by themotor branch of the median nervewith the exception of the adductorpollicis muscle, which is supplied bythe deep motor branch of the ulnarnerve. The hypothenar muscle groupis composed of the abductor digitiminimi, flexor digiti minimi, andopponens digiti minimi muscles. Thehypothenar muscle group, the threevolar interosseous muscles and thefour dorsal interosseous muscles, aresupplied by the ulnar nerve. The lum-brical muscles, which arise from theFDP tendon of each digit to insertlaterally on the extensor hood, areinnervated by both median and ulnarnerves. Specifically, the two lateralmuscles are innervated by the mediannerve, and the two medial musclesare innervated by the ulnar nerve.The dorsal forearm muscles areinnervated by the radial nerve (poste-

Volar musculatureSuperficialPronator teresFlexor carpi radialisPalmaris longusFlexor carpi ulnarisM iddleFlexor digitorum sublimisDeepFlexor digitorum profundusFlexor pollicis longusPronator quadratusDorsal musculatureSuperficialBrachioradialisExtensor carpi radialis longusExtensor carpi radialis brevisExtensor digitorum communisExtensor digiti minimiExtensor carpi ulnarisAnconeusDeepSupinatorAbductor pollicis longusExtensor polli cis brevisExtensor pollicis longusExtensor indicis

Fig. 7. Volar and dorsal forearmmusculature. (Reprinted with permssionfrom Donatelli R, Wooden M (eds),Orthopaedic Physical Therapy New York,NY, Churchill LivingstoneInc, 1989,p211.)rior interosseous nerve). These muscles are also arranged within two layers in the forearm.The extensor tendons are containedwithin six compartments at the levelof the wrist (Fig. 9). The first compartment contains the extensor pollicisbrevis and abductor pollicis longustendons. When these tendons developtenosynovitis from overuse or diseasepathology, it is usually described asdeQuervain's syndrome. Compartment two contains the extensor carpiradialis longus and extensor carpiradialis brevis tendons. Compartmentthree contains the extensor pollicislongus tendon. This tendon takes a45-degree turn at L ister's tubercle totravel distally to the thumb. Theextensor digitorum communis andextensor indicis tendons are foundwithin the fourth compartment. Compartment five holds the extensor digitiminimi tendon, and the extensor

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carpi ulnaris tendon is contained incompartment six.The median nerve enters the handthrough the carpal tunnel. M otor andsensory nerve fibers pass deep to thevolar carpal ligament, and occasionallyvariation is observed in the routing ofthe motor branch of the mediannerve. This branch, which innervatesthe thenar muscle groups, may passdeep to or superficial to the volarcarpal ligament.23,24The ulnar nerve enters the handthrough the tunnel of Guyon, orGuyon's canal, which is a spaceformed under the pisohamateligament.2,23,25 The nerve is subjectto variation at this level because itcan pass through the tunnel withboth sensory and motor components or as the motor branch only.This anatomical variation of theulnar nerve results in variation ofclinical presentation followingtrauma or transient compression.Dorsally, the radial nerve is presentin the hand via its sensory branch,the superficial radial nerve. Themotor branch, the posteriorinterosseous nerve, innervates thedorsal extrinsic musculature onlyand does not innervate the intrinsicmusculature.SkinThe most superficial structure of thehand is the skin. It provides a durable covering, which is highly innervated volarly for efficient tactilegnosis.26 The volar surface isendowed with fixed fat pads inaddition to numerous eccrineglands, which aid in nonslip grasping. The various lines or creases ofthe skin follow the normal stressesimposed by the movements of thehand. Extensibility and innervationof the skin are extremely importantto ultimate function of the hand.The hand is innervated volarly bythe median and ulnar nerves; dor-sally, it receives innervation from allthree nerves. On the volar surface,the thumb and the index and long

fingers are innervated by themedian nerve. The ulnar nerve supplies sensation to the ring and littlefingers. Because the crossover areaof the median and ulnar nerves caninclude shared innervation of thelong and ring fingers, the autonomous zones for the median nerveand the ulnar nerve innervation arethe index and little fingers,respectively.2,24,27

Dorsally, the superficial radial nervesupplies the area from the thumb tothe long finger from the level of thewrist distal to the PIP joints of theindex and long fingers. The areafrom the PIP joint to the tip isinnervated by the median nerve.The ulnar nerve innervates the areafrom the wrist to the tip of the ringand little fingers on the medialaspect of the dorsal hand.

Fig. 8. Volar and cross-sectional views of flexor tendons and volar structureatwrist level. In this representation, the flexor retinaculum is labeled thevolar carpal l igament. (Reprinted withpermission from LampeEW. Surgical anatomy of thehand. CibaClin Symp21(3)25, 1969.)20/1012 Physical Therapy/V olume 69, Number 12/December 1989


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Fig. 9- Dorsal and cross-sectional views of extensor tendons at level ofwrist.(Reprintedwith permission from LampeEW: Surgical anatomy of thehand. Ciba ClinSymp 21(3)29, 1969.)S umma r yThis article presented a functionalreview of hand anatomy to assist thegeneral clinician in gaining a betterunderstanding of the hand. A lthoughcomplex, the numerous structures arearranged to maximize function. Capsular and extracapsular structureswere discussed, and an overview ofthe muscle and nerve arrangementswas presented.

References1 Kapandji IA: The Physiology of the J oints.New York, NY , Churchil l L ivingstone Inc, 1970,vol 1, pp 154-164, 180-1852 Warwick R, Williams DP (eds): Gray's Anatomy: British Edition, ed 35. Philadelphia, PA,WB Saunders Co, 19733 Hakstian RW, Tubiana R: Ulnar deviation ofthe fingers: The role of joint structure andfunction. J Bone J oint Surg [Am] 49:299-316,19674 Holcomb G, Irving T, Smith RD: Coronaldeviation and tilt in the proximal interpha-langeal joints of man. J ournal of A nthropology16:429-440, 1958

5 Eaton RG, L ittler WJ: A study of the basaljoint of the thumb. J Bone J oint Surg [Am]51:661-668, 19696 Pieron AP: The mechanism of the first carpometacarpal (CM C) joint. Acta Orthop Scand,Supplement 148, 19737 Wise KS: The anatomy of the metacarpophalangeal joints with observations of the etiologyof ulnar drift. J Bone J oint Surg [Br] 57:185-190, 19758 Bojsen-Moller F: Osteoligamentous guidanceof the movements of the human thumb. AmJAnat 147:71-79, 19769 Kuczynski K: Carpometacarpal joint of thehuman hand. J Anat 118:119-126, 197410 M inami A, An K, Cooney WP, et al: Ligament stabil ity of the metacarpophalangealjoint: A biomechanical study. J Hand Surg [Am]10:255-260, 198511 Pagowski S, Phkarski K : Biomechanics ofthe metacarpophalangeal joint. J Biomech10:205-209, 197712 Bowers WH, Wolf JW, Nehil J, et al: Theproximal interphalangeal joint volar plate: I.An anatomical and biomechanical study. JHand Surg [Am] 5:79-82, 198013 L ittler WJ: Hand structures and function. InL ittler WJ, et al (eds): Symposium on Reconstructive Hand Surgery. St Louis, MO, C VMosby Co, 1974, vol 9, pp 3-1214 Zancolli E: Structural and Dynamic Basesof Hand Surgery. Philadelphia, PA, J B L ippin-cott Co, 196815 Eaton RG: J oint Injuries of the Hand.Springfield, IL, Charles C Thomas, Publisher,1971, pp 9-5016 Kuczynski K : The proximal interphalangealjoint. J Bone J oint Surg [Br] 50:656-663, 196817 Kuczynski K: Less-known aspects of theproximal interphalangeal joints of the humanhand. The Hand 7:31-33, 197518 Shrewsbury MM, Johnson RK: Ligaments ofthe distal interphalangeal joint and the malletpositi on. J Hand Surg [Am] 5:214-216, 198019 Eyler DL, M arkee J E: The anatomy andfunction of the intrinsic musculature of thefingers. J Bone J oint Surg [Am] 36:1-9, 195420 Smith RJ: Balance and kinetics of the fingers under normal and pathological conditions. Clin Orthop 104:92-111, 197421 L andsmeer JMF: Anatomical and functionalinvestigations on the articulation of the humanfingers. Acta Anat (Basel) 25:5-69, 195522 Gardner ED, Gray DJ, O'Railly R: Anatomy:Regional Study of Human Structure, ed 4. Philadelphia, PA, W B Saunders Co, 1975, pp 130-13923 Spinner M, Spencer P: Nerve compressionlesions of the upper extremity. Clin Orthop104:46-67, 197424 Kaplan EB: Functional and Surgical Anatomy of the Hand, ed 2. Philadelphia, PA, J BL ippincott Co, 196525 Gross MS, Gelberman RH: The anatomy ofthe distal ulnar tunnel. Clin Orthop 196:238-247, 198526 Riordan DC: Functional anatomy of thehand and forearm. Orthop Clin North Am5:199-202, 197427 Fetrow KO: Practical and important variations in sensory nerve supply to the hand. TheHand 2:178-184, 1970

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1989; 69:1007-1013.PHYS THER.Christine A MoranAnatomy of the Hand

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