Layer-by-layer topography of the hand area. Operative surgery and topographic anatomy: lecture notes for universities (A. V. Fishkin) Palmar surface of the hand
Flexor tendons, arteries and nerves of the hand
Palmar surface of the hand: superficial preparation
Synovial sheaths and tendons of the hand
Vermiform muscles, spaces and synovial sheaths
Finger flexor and extensor tendons
Deep muscles of the hand
Arteries and nerves of the hand: palmar surface
Brush: radial side
Brush: back
Brush: deep structures 
400. Superficial palmar arch
1 - a. ulnaris;
2 - os pisiforme;
3 - arcus palmaris superficialis;
4 - aa. digitales palmares communes;
5 - a. digitales palmares propriae;
6 - r. palmaris superficialis a. radialis;
Vessels and nerves of the palmar surface of the left hand: 1 - own palmar digital artery; 2 - common palmar digital artery; 3 - own palmar digital nerve (from the ulnar nerve); 4 - superficial palmar arch; 8 - common palmar digital nerve (from the ulnar nerve); c - muscle that abducts the little finger; 7 - short flexor of the little finger; 8 - deep palmar branch ulnar artery; 6 - deep palmar branch of the ulnar nerve; 10 - palmar branch of the ulnar nerve; 11 - ulnar artery; 12 - ulnar veins; 13 - median nerve; 14 - radial artery; 15 - palmar branch of the median nerve; 16 - superficial palmar branch of the radial artery; 17 - flexor tendon retinaculum; 18 - abductor pollicis brevis muscle; 19 - short flexor pollicis; 20 - common digital palmar nerve (median nerve); 21 - adductor pollicis muscle; 22 - lumbrical muscle; 23 - tendon of the superficial flexor of the fingers; 24 - fibrous sheath of fingers.
Rice. 161. Fascia and fascial sheaths of the hand. Transverse section at the level of the metacarpal bones: 1 - palmar aponeurosis; 2 - deep cellular fissure of the middle cellular space of the hand; 3 - muscle that abducts the little finger; 4 - metacarpal bones (III, IV and V); 5 - dorsal fascia of the hand; 6 - dorsal subfascial space; 7 - second dorsal interosseous muscle; 8 - first dorsal interosseous muscle; 9 - proximal phalanx of the thumb; 10 - flexor pollicis longus tendon; 11 - I and II lumbrical muscles; 12 - superficial cellular fissure of the middle cellular space.
Rice. 3.43. Cross section of the hand (diagram). Fascial beds of the palm: 1 - short thenar muscles; 2 - tendo m. flexor pollicis longus; 3 - vertical part of the lateral intermuscular septum; 4 - fascia propria; 5 - subgaleal cellular space; 6 - aponeurosis palmaris; 7 - a. et n. digitalis palmaris communis; 8 - tendines mm. flexoris digitorum superficialis; 9 - medial intermuscular septum; 10 - short muscles of the hypothenar; 11 - common synovial sheath of the digital flexors; 12 - dorsal interosseous fascia; 13 - palmar interosseous fascia; 14 - tendines mm. flexoris digitorumprofundus; 15 - subtendinous tissue space; 16 - a. metacarpalis palmaris; 17 - palmar interosseous muscle; 18 - dorsal interosseous muscle; 19 - m. lumbricalis; 20 - horizontal part of the lateral intermuscular septum; 21 - thenar cellular space; 22 - I dorsal interosseous muscle; 23 -m. adductor pollicis
Rice. 1. Transverse section of the right hand at the level of the wrist: 1 - extensor pollicis brevis tendon; 2 - radial artery; 3 - radial vein; 4 - scaphoid bone; 5 - tendon of the long extensor pollicis; 6 - extensor carpi radialis longus tendon; 7 - tendon of the short extensor carpi radialis; 8 - capitate bone; 9 - extensor tendon; 10 - extensor tendon of the index finger; 11 - hamate bone; 12 - extensor tendon (to the little finger); 13 - extensor tendon of the little finger; 14 - extensor carpi ulnaris tendon; 15 - triangular bone; 16 - flexor carpi ulnaris tendon; 17 - pisiform bone; 18 - tendons of the deep flexor of the fingers; 19 - tendons of the superficial flexor of the fingers; 20 - ulnar nerve; 21 - ulnar artery; 22 - ulnar vein; 23 - short palmaris muscle; 24 - tendon of the palmaris longus muscle; 25 - median nerve; 26 - flexor pollicis longus tendon; 27 - flexor carpi radialis tendon; 28 - tendons of the adductor pollicis muscle.
Rice. 9. Superficial nerves and veins of the dorsal surface of the left hand: 1 - dorsal digital nerves; 2 - intercapitate veins; 3 - lateral saphenous vein of the arm; 4 - superficial branch of the radial nerve; 5 - medial saphenous vein of the arm; 6 - dorsal branch of the ulnar nerve; 7 - venous arches of the fingers.
Rice. 7. Vessels and nerves of the palmar surface of the left hand: 1 - own palmar digital artery; 2 - common palmar digital artery; 3 - own palmar digital nerve; 4 - palmar aponeurosis; 5 - short palmaris muscle; 6 - palmar branch of the ulnar nerve; 7 - ulnar artery; 8 - palmar branch of the median nerve; 9 - branch of the lateral cutaneous nerve of the forearm.
In the area of the wrist joint there are three channels, resulting from the presence here retinaculum flexorum.
Spreading in the form of a bridge from eminentia carpi ulnaris to eminentia carpi radialis, it turns a trench 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 there are the ulnar nerve and vessels, which continue here from the sulcus ulnaris of the forearm. IN canalis carpi radialis lies the tendon of m. flexor carpi radialis, surrounded by a synovial sheath.
Finally, in canalis carpalis there are 2 separate synovial vaginas: 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 flexor 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 is a long and narrow canal that contains the tendon of the flexor pollicis longus. At the top, the vagina also protrudes 1-2 cm proximal to the retinaculum flexorum, and at the bottom 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 joints to the base of the nail phalanges. Consequently, the 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 fifth finger, but 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 superficial flexor tendons, the other between them and the deep flexor tendons, and the third 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, growing to the ridges 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 located inside the vagina are connected to their walls through thin mesenteries, mesotendineum, bearing blood vessels and nerves.
Educational video anatomy of the synovial sheaths of the tendons of the hand
Surgical anatomy fingers of the hand. Technique for opening paronychia, subcutaneous panaritium and tenosynovitis. Amputation and disarticulation of fingers.
Skeleton: phalanges distal, middle, proximal.
Joints: metacarpophalangeal and interphalangeal.
Muscles: flexors and extensors in the form of tendons, separately the muscles of the eminence of the 1st and 5th fingers. The tendon sheaths of the 1st and 5th fingers are longer, which creates the opportunity for the spread of pus into the Pirogov-Paron space.
Each finger has 4 arteries.
Innervation according to the UMRU type.
The finger flexors have different tendon attachments to the phalanges of the fingers.
Paronychia: based on the location, wedge-shaped, U-shaped and paired lateral incisions are used on the dorsal surface of the nail phalanx. It is necessary to close up to the unaffected elbow bed.
Subcutaneous panaritium: oval, arched, linear-lateral cuts. Necrotic areas are excised, revealing purulent focus along the entire length with subcutaneous tissue directly above the zone of purulent tissue melting.
For tenosynovitis along the lateral surface of the 1st or 5th fingers to their proximal end of the eminence. In case of leakage into Pirogov's space, an incision is made from the side of the forearm according to Canavell.
Amputation: the flap is opened from the palmar side, and the scar remains on the back. The incision is made from the dorsum to the palmar surface; after dissecting the bone and joint, they are cut off from the palmar flap.
Disarticulation: when isolating fingers, a single-flap method is used so that the scar is located, if possible, on the non-working surface: for the 3rd and 4th it is the dorsal surface, for the 2nd it is the ulnar and dorsal, for the 1st it is the dorsal and radial.
Surgical anatomy of the brachial plexus, its sections, branches. Skin innervation and group innervation of muscles upper limb. Quick access to main nerves upper limb. Nerve operations: nerve suture, neurolysis.
Brachial plexus formed by the 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 leaving the interscalene space, they are divided into supraclavicular and subclavian parts, in which they are divided into medial, lateral, and posterior bundles.
From the lateral fascicle: the musculocutaneous nerve and the platinum peduncle of the median nerve.
From medial bundle: medial thoracic, medial root of the median nerve, ulnar, medial cutaneous nerve of the shoulder and forearm.
From posterior beam: subscapular nerve, thoracodorsal, radial, axillary.
From the 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 approaches along projection lines in neurovascular bundles.
The radial nerve is allocated to opposite side forearm from the ulnar nerve: on the shoulder along the edge of the latissimus muscle, then obliquely and downward from the medial groove of the biceps. Ulnar 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 of the subscapularis muscle.
Nerve suture:
Accurate comparison of excised fascicles without trauma. The edges are sutured at the time of planned surgical treatment in order to create favorable conditions for healing.
Epineural suture: suturing the epineurium with the comparison of the perineurium and the fibers of the trunk using interrupted sutures is indicated for damage to the digital nerves or after excision of a parietal neuroma.
Perineural suture: restoration of the nerve by suturing the perineurium, optimal conditions are created for nerve regeneration, threads are applied separately to each bundle, restoration begins with deep-lying posterior bundles.
Neurolysis: an operation aimed at freeing a nerve from scar adhesions that cause pinching after blunt injury or pinching or bone fracture. Excise 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 spread of hematomas and purulent processes. Incisions for phlegmon of the gluteal region.
Borders: Bounded by the iliac crest, gluteal fold, line connecting the anterior iliac spine with the greater trochanter, sacrum and coccyx.
Landmarks: anterior and posterior superior ischial spines, iliac crest, sacrum, coccyx, ischial tuberosity, greater trochanter of the femur.
Layer anatomy: the skin is thick, dense, with a large number of sebaceous and sebaceous glands, body fat well defined, there is a subcutaneous trochanteric bursa, the superior nerve of the buttock, the lower nerve of the buttock, the middle nerves of the buttock, branches of the superior and inferior gluteal arteries and veins. Next is the superficial fascia. The gluteal fascia forms the sheath of the gluteus maximus muscle. Next, 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 (the bursa of the gluteus maximus muscle is located above the greater trochanter). Next are the gluteus medius, piriformis, superior gemellus, obturator internus tendon, inferior gemellus and quadratus, gluteus minimus and obturator externus, iliacus and ischiocis.
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 spread of hematomas and purulent processes: in the ischiorectal 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 for opening paronychia, subcutaneous panaritium and tenosynovitis. Amputation and disarticulation of fingers. - concept and types. Classification and features of the category "Surgical anatomy of the fingers. Technique for opening paronychia, subcutaneous panaritium and tendovaginitis. Amputation and disarticulation of the fingers." 2017, 2018.
Brush (manus)– distal part of the upper limb.
brush border
The area of the upper limb located distal to the plane drawn through the tips of the styloid processes of the bones of the forearm.
The hand is divided into three parts: the wrist area ( carpus), distal to which is the metacarpus area (metacarpus) and fingers (digiti manus) .
The palmar surface of the hand is distinguished (palma manus) and back (dorsum manus) . The lateral sections of the palm look like elevations formed by the muscles of the thumb (thenar) and little finger (hypothenar) . The middle section of the palmar cavity contains the digital flexor tendons (with the lumbrical muscles) and the interosseous muscles.
On the radial side on the back of the hand, with the thumb abducted, there is a triangular-shaped depression called "anatomical snuffbox".
Borders are
from the radial side tendons m. abductor pollicis longus And m. extensor pollicis brevis,
With ulnar– tendon m. extensor pollicis longus.
By bottom From this depression formed by the scaphoid and greater polygonal bones, the radial artery passes (from the palmar surface to the dorsum) (a. radialis) , which can be pressed against the scaphoid in case of bleeding.
Wrist
abovelimited horizontal line extending 1 cm. proximal to the styloid processes of the radius and ulna,
from below– a line drawn distal to the pisiform bone (corresponds to the distal transverse folds of the wrist).
Lines passing through the styloid processes divide the wrist into anterior and posterior regions.
The bone base is made up of eight carpal bones arranged in two rows. Proximal row on the radial side – scaphoid (os scaphoideum) , semilunar (os lunatum) , triangular (os triquetrum) and pisiform (os pisiforme) ;
distal row– trapezium bone (os trapezium) , trapezoidal (os trapezoidum) , capitate (os capitatum) and hook-shaped (os hamatum) .
The bones of the proximal row, with the exception of the pisiform, participate in the formation of the wrist joint. An intercarpal joint is formed between the first and second rows.
2.2 Topographic anatomy of the wrist joint (articulatio radiocarpea).
Wrist joint educated articular surface radius , which articulates with scaphoid And semilunar bones. The head of the ulna does not reach the bones of the wrist, and the lack of bone is filled with cartilage - fibrocartilago triangularis, which serves as the articular surface for the triquetral bone.
Joint capsule attaches to the edges of the articular surfaces and strengthened next ligaments:
behind dorsal radiocarpal (lig. radiocarpeum dorsale),
front palmar wrist ( lig. radiocarpeum palmare)
palmar ulnarcarpal (lig. ulnocarpeum palmare) ,
laterally radial collateral( lig. collaterale carpi radiale) ,
medially ulnar collateral (lig. collaterale carpi ulnare).
Weak spots wrist joint:
synovial saccular volvulus (recessus saccifomis)
cartilage – fibrocartilago triangularis
Blood supply: rete carpi palmare et dorsale, formed by the branches of the radial, ulnar and interosseous arteries.
Innervation: branches of the radial, ulnar, anterior and posterior interosseous nerves.
Projection joint:
In front, the joint is projected onto the proximal palmar skin fold of the wrist.
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