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•
• Autologous breast reconstruction using abdominal flaps
18
Figure 18.16 Note the distortion of the lines towards the side of closure.
Figure 18.17 Seen here on one side only, staples were used identically on the
contralateral side. Also note the turning of the pedicle around the costal margin.
Figure 18.18 Abdominal wall closure. (A) Standard primary closure without mesh. (B) In this case, the abdominal wall fascial defect was insufficient to allow primary
closure. Polypropylene mesh was used to span the gap and provide added strength. On-Q infusion catheters (I-Flow Corporation, Lake Forest, CA) are placed for pain control
and JP drains are left for drainage. The umbilical stalk is reset in an appropriate position as the superior flap is draped over the donor site.
A
B
Figure 18.19 (A,B) Simultaneous fascial closure distributes tension across the abdomen and aids in primarily closing the fascial defects.
A
B
289
Operative techniques
• Laterally, the TRAM flap should be tacked to the chest
wall to define the lateral contour of the breast as sharply
as possible. However, any sutures placed through TRAM
tissue for positioning purposes should be tied down
relatively loosely to avoid localized areas of fat necrosis
(see Fig 18.5).
• The flap is inset in layers using absorbable deep dermal
sutures and a running subcuticular skin closure.
Free TRAM (Fig. 18.21; Video 18.2)
• The dissection of the free TRAM flap begins in similar
fashion to that described above for the pedicled
TRAM through creation of the superior abdominal flap
(Fig. 18.22).
• Of course, in free TRAM techniques, the IMF tunnel is
not necessary.
• While making the inferior incision, the superficial inferior
epigastric vessels are encountered bilaterally in the
midinguinal region. At this point, if sufficient for use
(palpable arterial pulse, large vein), one should consider
the possibility of performing an SIEA flap (Video 18.3). If
insufficient for use, they may be ligated and divided,
although preserving a large vein for additional or
alternate drainage should be considered even if
performing a TRAM.
• The dissection is carried down to the fascia and
the lateral apices of the flap may be dissected off the
fascia.
• The dissection is carried from lateral to medial up to the
point of the identification of the lateral row of perforators
projecting through the rectus fascia into the subcutaneous
tissue of the flap.
• If performing a unilateral reconstruction, the side of the
flap opposite the vascular pedicle (zones II and IV) may
be completely dissected off the abdominal wall and
carried up to the point of the medial row of perforators
on the pedicle side (across the midline).
• If a bilateral flap is being performed, division of the flap
in the midline will aid in the medial row dissection on
either side.
• A decision is made at this point to use either the medial
perforators, lateral perforators, or both.
• The fascia is incised vertically and circumferentially
to incorporate the chosen perforators, creating an island
of excised fascia as part of the flap. The size of this
excised fascia depends on the number of perforators
chosen.
• Next, the surgeon identifies the vascular pedicle posterior
to, and at the lateral edge of the rectus muscle.
• It should be followed as far down to the external
iliac vessels as possible, but should not be divided
until the recipient site is ready for anastomosis and
insetting.
• After division of the pedicle, the rectus muscle is divided
inferiorly to the perforators, allowing for tension free
release of the pedicle.
• Lastly, the superior muscle is divided; however, care
must be taken to identify and oversew the superior
pedicle to prevent bleeding.
least 1 cm back on the fascia, and each bite advances
1–2 cm inferiorly on the fascia. The closure is completed
with the double stranded suture, and fascial staples are
added on both sides over the suture line for additional
support.
• If there is any concern about the abdominal wall closure,
Prolene mesh support is added over the closure once it is
completed.
• The Prolene mesh, if used, is used in a double layer and
is sutured in place using 0-Prolene in a running and
interrupted manner (Fig. 18.20).
• The abdominal skin is closed in layers over closed
suction drains in similar fashion to that performed during
aesthetic abdominoplasty procedures, including
umbilicoplasty.
Flap inset/breast shaping
• After closure of the abdominal wall, adequate time will
have passed to observe any vascular compromise. The
flap should have good pink color at this time.
• If any significant duskiness is noted, one may release the
clips on one or both inferior epigastric veins to
decompress the flap. Additionally, the tunnel width
should be re-evaluated.
• By the time the flap is de-epithelialized, red healthy
bleeding should be observed from the dermis. If not, the
pedicle should be examined visibly for undue twisting
and with the sterile Doppler for arterial inflow.
• Shaping of the TRAM in the immediate setting is
significantly assisted by the presence of native skin on
the chest. While there are many variations of remaining
skin after skin sparing mastectomies, the idea is to leave
a remaining skin envelope which will cover the TRAM
flaps with mild but not undue tension.
• The TRAM flap is sutured internally in the pocket
medially, superiorly and laterally to stabilize the flap on
the chest wall so that the skin closure will effect the final
shaping.
• It is important to adequately fill any deficit in the
infraclavicular location (superior pole), as this is an
extremely important aesthetic subunit of the breast.
Figure 18.20 Double layer prolene mesh.
Video
18.2
Video
18.3
290
•
• Autologous breast reconstruction using abdominal flaps
18
A
B
D
C
Figure 18.21 The final results. (A) Preoperative photograph, note the patient has a recent periareolar incision for a breast biopsy. (B) Postoperative following a right free
TRAM flap and subsequent NAR reconstruction with tattooing for color. (C) Preoperative photograph of a patient with previous bilateral mastectomies. (D) Postoperative
following a bilateral muscle sparing free TRAM with subsequent NAR and reconstruction with tattooing for color. Note there is a significantly higher utilization of the skin from
the flap for creation of an envelope.
• The degree of muscle sacrificed is dependent on the
anatomic variability of the perforators and can range
from no muscle sacrifice (DIEP or MS-3), central excision
only (MS-2), medial or lateral excision (MS-1), or to
complete transection of the lower rectus (MS-0)
(Fig. 18.23).
• The two most common recipient vessel sites in free tissue
reconstruction of the breast are the thoracodorsal vessels
and the internal mammary vessels (Fig. 18.24).
• In immediate breast reconstruction following a modified
radical mastectomy, the thoracodorsal vessels are either
fully or partially exposed.
• The thoracodorsal vessels are usually chosen as long as
the autologous flap for reconstruction has a sufficiently
long donor pedicle.
• End-to-end anastomoses are performed using either
interrupted 8-0 or 9-0 nylon sutures for both the artery
and vein or using sutures for the artery and a coupler for
the vein.
• In the setting of delayed breast reconstruction,
some surgeons choose the thoracodorsal recipient
vessels because of their familiarity with flap insetting
and because of the proven efficacy of these vessels in
delayed reconstruction. But, for many surgeons, the
internal mammary vessels are the recipient vessels of
choice.
• Advantages of internal mammary recipient vessels:
■ Avoidance of surgery within the axilla that has been
scarred from previous surgery.
■ Allows a more medial positioning of the flap for
improved symmetry and aesthetics.
■ The internal mammary vessels have also
been used preferentially when mastectomy
combined with sentinel node biopsy is
performed.
• The internal mammary vessels are first approached by
separating the fibers of the pectoralis muscle overlying
the third costal cartilage (Fig. 18.25).
291
Operative techniques
E
F
G
H
(E) Preoperative photograph in a patient with a recent left axillary sentinel lymph node biopsy and significant ptosis. (F) Postoperative following a left
free TRAM via a Wise pattern with concomitant balancing right mastopexy. She has yet to undergo NAR. (G) Preoperative photograph of a patient with bilateral malignancies.
(H) Postoperative following bilateral skin sparing mastectomy with free TRAM reconstruction.
Figure 18.21, cont’d
• Self-retaining retractors are placed perpendicularly,
exposing the cartilage and intercostal musculature.
• The perichondrium is incised along the midanterior surface
from the junction of the sternum to 1–2 cm medial to the
costochondral junction and separated off of the cartilage,
first on the anterior surface and then extending to its
posterior surface. Complete separation of the posterior
perichondrium can be difficult and is unnecessary.
• Once the perichondrium is partially separated on the
upper and lower edges of the costal cartilage, a rongeur
is used to remove the cartilage.
• The deep perichondrium is then incised lateral to the
internal mammary vessels and reflected lateral to medial.
Care must be taken to avoid transection of the small
intercostal vessel branches coming off the internal
mammary system.
• Once the vessels are identified and separated from the
internal mammary lymphatics, the length of dissection is
extended by dividing the intercostal musculature from
the top of the fourth rib to the bottom of the second rib;
this is done by staying lateral to the internal mammary
vessels.
• As compared with most other recipient vessels
throughout the body, the internal mammary artery is
more susceptible to injury and thrombosis during its
dissection. Minimal use of vascular forceps is
recommended.
• The internal mammary vein tends to be larger on the
right side than on the left side. Although the third
cartilage is currently recommended, the second cartilage
can be similarly removed for access to a recipient vein of
greater diameter.
292
•
• Autologous breast reconstruction using abdominal flaps
18
A
B
C
D
E
F
Figure 18.22 Dissection of the free TRAM flap. (A) A superior abdominal flap is raised to allow for eventual tension free closure. The height of the TRAM flap is dependent
on the mobility of this flap. (B) The lateral flaps of the TRAM are raised to the point of the lateral perforators. (C) The umbilicus is preserved. (D) An anterior rectus sheath
fasciotomy is made above and below the perforators. (E) Within the rectus sheath, the muscle is reflected medially to allow for visualization and dissection of the inferior
epigastric vessels. (F) The perforators are identified and preserved as they traverse the muscle. This allows for preservation of at least the lateral aspect of the rectus muscle
for a muscle sparing free TRAM.
293
Operative techniques
G
H
I
J
K
(G) After the recipient site is prepared, the vascular pedicle is clamped and divided inferiorly to allow for ample pedicle length. (H) The pedicle is
passed through the middle of the rectus muscle in the plane of the perforators. (I) The inferior muscle is divided. (J) The superior muscle is divided. (K) The flap is ready
for anastomosis.
Figure 18.22, cont’d
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•
• Autologous breast reconstruction using abdominal flaps
18
Figure 18.23 The variations of a free TRAM. (A) The MS-0 flap in which the rectus muscle is completely transected. (B) The MS-I spares the lateral band preferably (as
opposed to the medial band) of muscle with the goal of preserving the innervation of the muscle. (C) In an MS-II flap, only a small central portion of the rectus muscle
around the perforators is transected. (D) The MS-III, otherwise known as a DIEP, preserves the entire rectus muscle.
A
MS-I
B
MS-II
C
DIEP
D
295
Operative techniques
• Once fully dissected, the internal mammary artery and
vein are divided at the level of the fourth rib and
supported on their deep surfaces by a neurosurgical
sponge (Fig. 18.26).
• The free flap is temporarily positioned to allow easy
performance of the anastomoses. Sutures of 9-0 nylon
may be used for both anastomoses; however, the internal
mammary artery is at times quite large, requiring 8-0
nylon. The vein is usually amenable to use of the coupler
device.
• Other potential recipient vessels include the scapular
circumflex vessels, the thoracoacromial vessels, and the
axillary artery and vein. These are rarely used as the
planned primary recipient vessel site; rather, they are
used when problems have occurred during surgery at
one of the two routine recipient vessel sites.
Flap insetting
• A decision as to whether to use an ipsilateral or
contralateral free flap has usually been made
preoperatively, based on the shape of the contralateral
breast, the timing of reconstruction and the planned
recipient vessels (Fig. 18.27).
• In general, when the thoracodorsals are used, a narrow
ptotic breast is reconstructed with an ipsilateral flap
which has been rotated 90° with the umbilicus positioned
in an inferomedial orientation.
• A less ptotic, but wide breast is reconstructed with a
contralateral free flap with the flap rotated approximately
140° such that the lateral aspect of the initial flap design
becomes the tail of the neo-breast mound. This may be
rotated up to 180° for increased width.
• If the internal mammary vessels are used, the concept is
the same except that the exact opposite is performed – a
Figure 18.24 The vascular anatomy of the chest wall. The two most common sites
for recipient vessel harvest and subsequent vascular anastomoses are the internal
mammary vessels and the thoracodorsal vessels.
contralateral flap is used for a narrow, pendulous breast
whereas an ipsilateral flap is used to construct a wider
breast mound.
• Once the anastomosis is complete and orientation
established, the buried portions of the flap are
de-epithelialized.
• The goal is to remove the epidermis and a portion of the
dermis; however, care should be exercised not to injure
the subdermal vascular plexus which likely helps with
more uniform perfusion of the edges of the flap.
• The flap is secured in place in multiple layers and the
skin closed with running 4-0 absorbable monofilament.
• If there is a question about the viability of the
mastectomy flaps prior to conclusion of the case, the
TRAM may be “banked” under the mastectomy flaps
without de-epithelialization. The patient returns to the
operating room 72 h later, after the skin flaps have fully
demarcated, at which time the TRAM flap can be
formally inset.
• Abdominal closure proceeds similarly to that described in
the pedicled TRAM technique
DIEP flap (Figs 18.28, 18.29; Video 18.4)
• Flap dissection is similar to that of the free TRAM
described above.
• While making the inferior incision, care is taken to
preserve the superficial epigastric vessels.
• If the venous drainage of the flap is insufficient or
thrombosis of the perforating vein(s) occurs after the
anastomosis, the superficial epigastric veins can be used
as an additional venous conduit.
• Two or three veins may be present but they
commonly unite further down the abdominal wall.
The veins are dissected over a length of 2–3 cm and
ligated with clips to make them easily retrievable later,
if needed.
• If the caliber of the superficial epigastric artery is noted
to be large enough, a similar skin island to the DIEAP
flap can be harvested on these two vessels.
• Dissection of the vascular pedicle of a DIEAP flap can be
divided into three different technical stages; suprafascial,
intramuscular and submuscular dissection. The most
demanding stage is the intramuscular dissection of the
vascular pedicle.
• Suprafascial dissection is carried out similar to free
TRAM procedures and proceeds laterally to medially up
to the lateral row of perforators (Fig. 18.30A,B).
• If the caliber of one vessel is estimated to be insufficient,
an adjacent perforator located on the same vertical line
can also be dissected.
• The abdominal wall muscles must be relaxed at all times
and the perforating vessels kept moist with normal
saline.
• When dissecting a perforator from the lateral side, it is
important to realize that a side branch may be located
more medially. Extra care must be taken when dissecting
the full circumference of a vessel, but complete dissection
helps prevent vessel damage when raising the flap from
the contralateral side (see Fig. 18.31C,D).
Video
18.4
296
•
• Autologous breast reconstruction using abdominal flaps
18
Figure 18.25 The vascular anastomosis to the internal mammary vessels. (A) The third rib is cleaned off, followed by (B) incision of the anterior perichondrium. (C) The
costochondral junction is removed with a rongeur. (D) Further dissection allows for exposure of the internal mammary vessels. (E) The anastomoses are performed.
A
B
C
E
D
297
Operative techniques
Figure 18.26 The internal mammary artery and two common veins on the right side after
removing a small part of the costal cartilage of the third rib.
Intercostal muscles
Sternum
Pectoralis major muscle
II
III
Horizontal result
Goal at end of
reconstruction
Timing of
reconstruction
Axillary status
Preferred choice for
recipient vessel
Side of abdominal flap
used relative to reconstruction
Without LND
With LND
Internal mammary
Thoracodorsal
Ipsilateral
Contralateral
No need for
axillary involvement
Internal mammary
Ipsilateral
Delayed
Immediate
A
Vertical result
Goal at end of
reconstruction
Timing of
reconstruction
Axillary status
Preferred choice for
recipient vessel
Side of abdominal flap
used relative to reconstruction
Without LND
With LND
Internal mammary
Thoracodorsal
Contralateral
Ipsilateral
No need for
axillary involvement
Internal mammary
Contralateral
Delayed
Immediate
B
Figure 18.27 Whether unilateral or bilateral, the standard
approach to insetting is shown in this algorithm and takes
in to consideration the overall goal, the timing of
reconstruction, node status, choice of recipient vessels
and the laterality of the flap. The goal of a wider, more
horizontal breast mound is shown in (A); whereas,
(B) depicts a more vertical, pendulous breast.
298
•
• Autologous breast reconstruction using abdominal flaps
18
Figure 18.28 (A) Preoperative image of a 46-year-old-woman, carrier of a BRCA-2 mutation, following tumorectomy through a horizontal racquet incision at the right
breast. (B) Intermediate phase after bilateral areola-sparing mastectomy, using the same scar on the right breast and a more conventional vertical scar on the left breast, and
bilateral autologous reconstruction by means of a bilateral free DIEAP flap. (C–E) A 2-year-postoperative image after bilateral nipple reconstruction using the interposed skin
island of the flap and bilateral tattoo.
A
B
D
C
E
• The anterior rectus fascia is then incised with a pair of
scissors following the direction of the rectus abdominis
muscle fibers at the rim of the tiny gap in the fascia
through which the perforating vessel passes (see Fig.
18.30E).
• If more than one perforator is dissected, the different
gaps can be connected with each other. A small cuff
of fascia may be left around the perforator if the
vessel is small or if the surgeon feels more comfortable
doing so.
• Lifting the fascia helps mobilize the perforator, which can
be freed by blunt dissection, gently pushing away the
loose connective tissue.
• The division of the fascia is continued superiorly for a
distance of 3–4 cm and inferiorly to the lateral border of
the rectus abdominis muscle in an oblique line towards
the inguinal ligament (see Fig. 18.30F).
• At this point the direction of the division of the fascia is
changed into the direction of the fibers of the external
oblique muscle.
299
Operative techniques
Figure 18.29 (A) Preoperative image of a 62-year-old woman following modified radical mastectomy of the
right breast and breast hypertrophy/ptosis of the left breast. (B) Intermediate phase after secondary
autologous breast reconstruction by means of a unilateral free DIEAP flap. (C–E) Final result, 1 year
postoperatively, after right nipple reconstruction (and later tattoo) and left breast reduction.
A
B
C
D
E
300
•
• Autologous breast reconstruction using abdominal flaps
18
A
B
C
D
Figure 18.30 (A) Incision of skin and subcutaneous tissue is extended towards the flanks if additional tissue is needed. The dominant perforator on the right side is marked
with an “x” on the flap. (B) The flap is laterally undermined towards medial until the area around the preoperatively marked perforator is reached. Undermining of the fat is
continued proximal and distal of the perforator. (C) Undermining continues around the perforator for a distance of about 2 cm. Lifting up the subcutaneous tissue is easier at
this point when the deep fascia is still closed. (D) Access to the perivascular loose connective tissue is sought by incising the gap in the deep fascia and the tissues
surrounding the vessels.
• It is important to emphasize that the vessels
must be protected at all stages and complete
muscle relaxation is necessary until donor site
closure is obtained. As dissection progresses, the
DIEAP flap should be secured to the abdominal wall
with the aid of staples.
• For the intramuscular dissection, the rectus abdominis
muscle should be split in a longitudinal direction in the
perimysial plane through which the perforating
vessel traverses. Splitting the muscle fibers makes
dissection easier as the vessel becomes larger (see
Fig. 18.30G).
301
Operative techniques
E
F
G
H
I
(E) The deep rectus fascia is incised vertically following the fibers of the rectus abdominis muscle both cranially and distally. The perforator is freed
in its supra-muscular parts. (F) In a next step, the deep fascia is opened all the way down to the infralateral border of the rectus muscle and further distally along its lateral
border to create exposure of the deep inferior epigastric artery and vein. (G) The rectus abdominis muscle is split following the muscle fibers until the posterior fascia or the
peritoneum can be seen. Sensory nerves come here from lateral and following the perforator can be transected. Motor nerves are left intact (white arrow). (H) Wide exposure
is achieved with a self-retaining retractor. A bloodless field allows perfect control of the dissection. The main axis of the deep inferior epigastric artery and its veins is
clipped proximal to the perforators (white arrow). (I) Once the entire course of the perforator and the main vessels is clear, the posterior part of the perforator and the main
vessels is dissected off the surrounding tissues. The distal part of the deep inferior epigastric vessels can be dissected either through the same incision through the rectus
muscle or continued from lateral by pulling the rectus muscle medially.
Figure 18.30, cont’d
302
•
• Autologous breast reconstruction using abdominal flaps
18
Figure 18.31 (A) Coronal, (B) sagittal and
(C) transverse view of the footprint of the breast.
A
B
C
Gland
Muscle
I
II
III
IV
V
VI
VII
Inframammary fold
• The perforator is again liberated by blunt dissection,
staying close to the vessel at all times, as it remains
covered by a thin layer of loose connective tissue.
• As a general rule, if resistance to dissection is
encountered, a side branch or a nerve will be identified.
Different muscular branches must be ligated with care
and hemoclips are placed 1–2 mm away from the main
vessel so that if one inadvertently comes off, it can easily
be replaced.
• Placing a vessel loop around the vascular pedicle allows
additional retraction without any unnecessary tension
being placed on the vessel.
• Using bipolar coagulating diathermy and small
hemoclips, one continues to ligate all the side branches
until the origin of the perforator on the major branch of
the deep inferior epigastric vessel is reached at the
posterior surface of the rectus abdominis muscle (see Fig.
18.30H).
• If two perforators have been selected, the rectus
abdominis muscle must be widely separated. If the
perforators run in two adjacent perimysial planes, the
fibers may have to be cut. However, trans-section of large
parts of the rectus abdominis muscle or division at the
level where a motor nerve crosses from the lateral to the
medial side should be avoided.
• For the submuscular dissection, the lateral border of the
rectus abdominis is raised using non-crushing tissue
forceps.
• Special care is taken not to injure the mixed segmental
nerves entering the muscle laterally. The sensory nerve
branch can be dissected by epineural splitting. In this
way, an additional 5–9 cm can be obtained, facilitating
neural suturing at the recipient site.
• Between the mixed segmental nerves, the plane posterior
to the rectus abdominis muscle is opened, exposing the
main deep inferior epigastric vessel. Side branches of the
main stem are ligated and the dissection is continued by
retracting the rectus abdominis muscle medially until the
proximal part of the pedicle is completely liberated.
• The length of the pedicle can be tailored to meet the
needs of different recipient sites or the demands of the
shape of the flap (see Fig. 18.30I).
• The more distal the perforator is located in the flap, the
further the deep inferior epigastric vessels need to be
dissected into the groin.
• If one is certain that the blood flow through the deep
inferior epigastric vessel is sufficient (an ultrasonic flow
meter can be used) the remainder of the flap can be raised.
• In cases of midline scars, or when a large flap is needed,
the same vascular dissection can be performed on the
contralateral side. Otherwise, all the remaining
perforators are ligated, the umbilicus is released and the
entire skin flap is raised.
• The pedicle is finally transected when the recipient
vessels have been prepared. A hemoclip can be
placed on the lateral comitant vein to help orientate the
pedicle.
• After division of the pedicle, the flap is turned over and
the vessels placed carefully onto its undersurface. One
has to be meticulous about the position of the pedicle, as
it tends to rotate very easily, especially if only one
perforator has been harvested.
303
Operative techniques
Abdominal closure
• Unlike TRAM techniques, since no fascia has been
resected, primary tension-free closure of the fascia with a
running, non-absorbable 1-0 suture is always possible.
The remainder of the wound is closed in similar fashion
to aesthetic abdominoplasty.
Flap inset
• DIEP flap inset is similar to that of TRAM techniques. A
systematic approach is applied to be able to create easy
and reproducible results in shaping of autologous tissue
by using the “3-step principle”.
• Recreating a 3-dimensional organ from a flat piece of
abdominal fat and skin is broken down into three
essential steps:
1. Redefining and recreating the basis and borders of
the footprint of the breast (the interface of the
posterior surface of the breast gland and the thorax)
at the right location on the chest wall (Fig. 18.31).
2. Molding the flap into a drop-shape like conus on top
of the footprint by means of specific suturing (Fig.
18.32).
3. Redraping the skin envelope (Fig. 18.33) and the
nipple areolar complex (Fig. 18.34) over the conus
with the right tension.
• While the position of the borders of the new breast
footprint are at a mirror position of the contralateral
footprint, the new inframammary fold position needs to
be placed 2–3 cm higher than the contralateral
inframammary fold depending on the laxity of the
Hints and tips
10 golden rules in perforator flap surgery
1. Map the perforators preoperatively: identify the most
dominant vessels on each side.
2. Start dissection on one side of the flap: leave the
contralateral side intact until you have finished the entire
dissection of the pedicle.
3. Preserve every perforator until you encounter a larger one:
discard only the smaller ones that you are sure you will
not use. Select one or two perforators with the largest
diameter that correspond with your preoperative mapping.
4. Consider the best location of the perforator within the flap:
the more centrally located, the better the blood flow to the
outer parts of the flap.
5. Consider the easiest dissection through the muscle: long
intramuscular dissections are more tedious, contain more
risk for damaging the vessels and are more
time-consuming.
6. Dissect close to the vessels, remaining within the
perivascular loose connective tissue, thereby guaranteeing
an absolute bloodless field.
7. Ensure sufficient and wide exposure by splitting the
muscle along its fibers (avoid digging into a small hole).
8. Carefully ligate every side-branch at a distance of about
2 mm away from the main pedicle.
9. Avoid any traction on the perforator: intima rupture is a
frequent cause of unexplained clotting of the perforator.
10. Trans-sect the other perforators after the entire pedicle is
dissected.
Figure 18.32 (A) Coronal, (B) sagittal and (C) transverse
view of the conus of the breast.
A
B
C
Gland
Muscle
I
II
III
IV
V
VI
VII
Inframammary fold
304
•
• Autologous breast reconstruction using abdominal flaps
18
Figure 18.33 (A) Coronal, (B) sagittal and (C) transverse
view of the envelope of the breast.
A
B
C
Gland
Muscle
I
II
III
IV
V
VI
VII
Inframammary fold
Figure 18.34 The nipple areola complex is an integral part of the envelope of the
breast.
mastectomy flap skin and tension exerted on the
abdominoplasty flap later in the procedure.
• To recreate the breast cone, three key sutures are utilized:
■ The tip of the DIEAP flap is fixed just below the
pectoralis tendon by suturing Scarpa’s fascia to the
pectoralis fascia 2–3 cm medial to the lateral pectoral
muscle border. This first key suture recreates the
anterior axillary fold (Fig. 18.35A,B).
■ The transition from the lateral pectoral border into the
lateral portion of the flap also recreates a natural lazy-S
shape along the lateral border of the breast. The exact
position of the second key suture is determined by
moving the flap along the inframammary fold while
assessing the lazy-S contour.
■ It is always better to have minimal fullness in this
location at the time of reconstruction, as the flap will
shift laterally and distally in the postoperative period.
■ Medial to the second key suture, in the midclavicular
line, the skin of the flap is then bunched up (see Fig.
18.35C). This dramatically increases flap projection. It
also helps create a sharp angle between the skin of the
flap and the abdominal skin below the inframammary
fold.
■ The third key suture is placed at the medial end of the
inframammary fold. The flap is not bunched in this
location to avoid overfilling of the inferomedial
quadrant of the new breast.
• Overfilling of the superomedial regions of the breast is
recommended (see Fig. 18.35D), as gravity will be pulling
the flap caudally over the ensuing 6 months. Excessive fat
can easily be removed later, whereas a depression in this
area can be very disturbing for the patient.
• Once the final volume of the flap is determined, one can
make a rough estimate of how much skin overlying the
DIEAP flap will be required. The flap can be pushed up
into the pocket or pulled down, leaving more or less
vertical skin height, respectively, on the skin paddle of
the flap.
• The more skin that is left, the more ptosis that can be
achieved.
305
Postoperative considerations
Figure 18.35 (A) The diep flap is turned 180° after performing the microsurgical anastomosis of the vessels and then (B) sutured with two key sutures to the pectoral
fascia at the anterior axillary fold and the lateral part of the new inframammary fold making sure to avoid any fullness of the inferolateral quadrant of the new breast. (C) A
triangular excision of skin around the umbilical area and gathering of the skin at the inframammary fold around the midclavicular line will create projection of the flap and a
sharp angle between the lower part of the breast and the abdominal wall. (D) The least vascularized part of the flap is then resected making sure to preserve enough tissue to
fill the upper medial quadrant of the breast.
A
B
C
D
Anastomosis
DIEAP flap
Sutures
Peri-umbilical
skin excision
Skin gathering
Least vascularized
part resected
Tissue added medially
• The more skin resected in the lateral part of the flap, the
more the flap will be pushed medially.
Postoperative considerations
• For pedicled TRAM procedures, patients generally spend
an average of 3 days in the hospital. Anticoagulation
protocols are not utilized.
• For free TRAM/DIEP patients, the patient is extubated,
transferred to the PACU and subsequently admitted to
either the ICU or a step-down type unit that has the
capability for frequent nursing flap checks and Doppler
evaluations.
• Our practice pattern is to continue Doppler checks
every hour for the first 48 h, then every 4 h until
discharge which typically is postoperative day (POD)
3 or 4.
306
•
• Autologous breast reconstruction using abdominal flaps
18
• If small areas of fat necrosis exist, they may be best
treated by excision because they could create concern for
cancer recurrence by any subsequent examining
physician.
• Other potential complications include: dog ears of the
abdomen, contour deformities, seromas, partial flap loss,
or total flap loss.
• Significant (>25%) or total flap loss in pedicled TRAM
cases is exceedingly rare (incidence <1%). Total flap loss
for free flap techniques occurs 0.2–4.7% of the time.
• Intuitively, the risk of abdominal bulge or abdominal
hernia should be directly related to the amount of rectus
muscle harvested/violated, such that the risk is greatest
for pedicled TRAM procedures and least for DIEP flap
procedures.
• Due to the microvascular anastomosis and operative
manipulation in free flap techniques, the artery and vein
are both subject to thrombosis.
• Delayed thromboses confer a more clinically detrimental
outcome; therefore, close observation of these flaps is
paramount in the immediate postoperative period.
• Venous congestion postoperatively can be treated with
leech therapy; however, sudden changes in flap character
or Doppler signal warrant exploration.
• In inexperienced hands, the DIEAP flap dissection will
require a longer operating time than a conventional
myocutaneous flap. After a number of cases, operating
time will fall back and be comparable to myocutaneous
flap harvesting or even shorter if a limited pedicle length
is needed.
Further reading
Alderman AK, Kuhn LE, Lowery JC, et al. Does patient
satisfaction with breast reconstruction change over
time? Two-year results of the Michigan Breast
Reconstruction Outcomes Study. J Am Coll Surg.
2007;204(1):7–12.
The Michigan Breast Reconstruction Outcomes Study was a
well designed prospective analysis of patients undergoing
breast reconstruction. This project resulted in several papers
which contributed a plethora of prospective data comparing
tissue expander, pedicled TRAM and free TRAM
reconstruction. In this article, long-term patient satisfaction
data are presented. Overall, patients undergoing free or
pedicle TRAM have higher satisfaction rates than tissue
expander/implant reconstruction at 1 year as measured by
survey quantifying overall satisfaction and aesthetic
satisfaction. At 2 years, although the difference in overall
satisfaction between treatment groups diminished, women
who underwent autologous reconstruction had higher
aesthetic satisfaction when compared with tissue expander/
implant reconstruction. This entire series of papers is worth
reading for anyone interested in breast reconstruction.
Allen RJ, Treece P. Deep inferior epigastric perforator flap
for breast reconstruction. Ann Plast Surg. 1994;32:
32–38.
Andrades P, Fix RJ, Danilla S, et al. Ischemic complications
in pedicle, free, and muscle sparing transverse rectus
• Pain control is best managed with a patient controlled
analgesic pump for the first 48 h at which point patients
can usually be transferred over to an oral regimen.
• The patient remains NPO until the morning of POD 1 at
which point they start clear liquids.
• Patients are encouraged to get out of bed to a chair on
POD 1 and to fully ambulate on POD 2 at which point
the Foley catheter is removed.
• Sequential compression devices are placed preoperatively
and are continued postoperatively while in bed until
discharge.
• Anticoagulation remains a controversial subject following
free flap breast reconstruction.
• At our institution, all surgeons utilize subcutaneous
heparin immediately after surgery both for DVT
prophylaxis and to maintain a mildly hypocoagulable
state following microanastomosis.
• The use of aspirin varies, with the goal of decreasing the
thrombosis rate without adding additional risk of
hematoma postoperatively.
• The use of prophylactic antibiotics for the prevention of
surgical site infection (SSI) is another area of controversy.
• We recommend at the very least, preoperative dosing of
Cefazolin within 30 min of incision, with re-dosing as
needed intraoperatively in prolonged reconstruction. The
data on postoperative prophylaxis while drains are in
remain limited and at this time should be at the
discretion of the operating surgeon.
• The drains are removed in the office over the next several
weeks, usually when the output of each is less than
30 cc/day.
• Extensive exercises and heavy lifting are limited until the
patient is 6 weeks postoperative.
Complications and outcomes
• Patient satisfaction is extremely high for abdominal based
breast reconstruction procedures.
• Autologous breast reconstruction creates a more natural
appearing and feeling breast when compared to implant
reconstructions.
• Secondary procedures are commonly performed for
contour irregularities, nipple-areolar complex
reconstruction.
• It is preferable to wait 2–3 months after the initial
procedure to perform a secondary procedure.
• If radiation is required postoperatively, it is preferable
to wait at least 6 months after the radiation has
been completed before performing any secondary
procedures.
• Common complications included mastectomy flap
necrosis and fat necrosis.
• If native skin loss is encountered in the early
postoperative period, it is probably best treated with
early excision and closure.
• The incidence of fat necrosis is reportedly 9% and greater
in pedicled TRAM flaps when compared to free TRAM or
DIEP flaps.
307
Further reading
abdominis myocutaneous flaps for breast
reconstruction. Ann Plast Surg. 2008;60(5):562–567.
This was a retrospective review at one institution comparing
ischemic complications between pedicled TRAM and MS-0
through MS-3 free TRAM reconstructions. Their data
follow theoretical predictions based upon anatomy: there is a
higher rate of fat necrosis in pedicled TRAMs when
compared with free TRAM. There is a trend toward higher
complication rates as the degree of muscle preservation
increases. The bulge and hernia rates were, however, no
different between groups. Although limited by a
retrospective design, this is one of many articles which gives
credence to improved outcomes with free versus pedicled
TRAM.
Baldwin BJ, Schusterman MA, Miller MJ, et al. Bilateral
breast reconstruction: conventional versus free TRAM.
Plast Reconstr Surg. 1994;93:1410–1416.
Pedicle versus free TRAMs and differences in perfusion.
Blondeel PN. One hundred free DIEP flap breast
reconstructions: a personal experience. Br J Plast Surg.
1999;52(2):104–111.
The transverse rectus abdominis myocutaneous (TRAM)
flap has been the gold standard for breast reconstruction
until recently. Not only autologous but also immediate
reconstructions are now preferred to offer the patient a
natural and cosmetically acceptable result. This study
summarizes the prospectively gathered data of 100 free
DIEP flaps used for breast reconstruction in 87 patients.
Primary reconstructions were done in 35% of the patients.
Well known risk factors for free-flap breast reconstruction
were present: smokers 23%, obesity 25%, abdominal
scarring 28% and previous radiotherapy 45%. Mean
operating time was 6 h 12 min for unilateral reconstruction
and mean hospital stay was 7.9 days. These data indicate
that the free DIEP flap is a new but reliable and safe
technique for autologous breast reconstruction. This flap
offers the patient the same advantages as the TRAM flap
and discards the most important disadvantages of the
myocutaneous flap by preserving the continuity of the rectus
muscle.
Blondeel PN, Boeckx WD. Refinements in free flap breast
reconstruction: the free bilateral deep inferior
epigastric perforator flap anastomosed to the
internalmammary artery. Br J Plast Surg.
1994;47(7):495–501.
Besides the enormous advantages of reconstructing the
amputated breast by means of a conventional TRAM flap,
the main disadvantage remains the elevation of small (free
TRAM) or larger (pedicled TRAM) parts of the rectus
abdominis muscle. In order to overcome this disadvantage,
the free deep inferior epigastric perforator (DIEP) skin flap
has recently been used for breast mound reconstruction with
excellent clinical results. After achieving favorable results
with eight unilateral DIEP-flaps, we were challenged by an
abdomen with a midline laparotomy scar. By dissecting a
bilateral DIEP flap and making adjacent anastomoses to the
internal mammary artery, we were able to achieve sufficient
flap mobility for easy free flap positioning and breast
shaping. Intraoperative segmental nerve stimulation,
postoperative functional abdominal wall tests and CT-scan
examination showed normal abdominal muscle activity. On
the basis of a case report, the technical considerations and
advantages of anastomosing the bipedicled DIEP flap to the
internal mammary artery are discussed.
Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the
breast in aesthetic and reconstructive breast surgery:
an easy three-step principle. Plast Reconstr Surg.
2009a;123(2):455–462.
Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the
breast in aesthetic and reconstructive breast surgery:
an easy three-step principle. Part II. Breast
reconstruction after total mastectomy. Plast Reconstr
Surg. 2009b;123(3):794–805.
This is Part II of four parts describing the 3-step principle
being applied in reconstructive and aesthetic breast surgery.
Part I explains how to analyze a problematic breast by
understanding the three main anatomical features of a breast
and how they interact: the footprint, the conus of the breast
and the skin envelope. This part describes how one can
optimize his/her results with breast reconstructions after
complete mastectomy. For both primary and secondary
reconstructions, we explain how to analyze the
mastectomized breast and the deformed chest wall before
giving step-by-step guidelines on how to rebuild the entire
breast with either autologous tissue or implants. The
differences in shaping unilateral or bilateral breast
reconstructions with autologous tissue are clarified.
Regardless of timing or method of reconstruction, it is
shown that by breaking down the surgical strategy in three
easy (anatomical) steps, the reconstructive surgeon will be
able to provide more aesthetically pleasing and reproducible
results.
Edsander-Nord A, Jurell G, Wickman M. Donor-site
morbidity after pedicled or free TRAM flap surgery: a
prospective and objective study. Plast Reconstr Surg.
1998;102(5):1508–1516.
Greco III JA, Castaldo ET, Nanney LB, et al. Autologous
breast reconstruction: The Vanderbilt Experience (1998
to 2005) of independent predictors of displeasing
outcomes. J Am Coll Surg. 2008;207(1):49–56.
Grotting JC, Urist MM, Maddox WA, et al. Conventional
TRAM flap versus free microsurgical TRAM flap for
immediate breast reconstruction. Plast Reconstr Surg.
1989;83(5):828–844.
Hartrampf CR, Scheflan M, Black PW. Breast reconstruction
with a transverse abdominal island flap. Plast Reconstr
Surg. 1982;69:216–224.
The seminal article on TRAM flaps.
Koshima I, Soeda S. Inferior epigastric artery skin flaps
without rectus abdominis muscle. Br J Plast Surg.
1989;42(6):645–648.
The rectus abdominis musculocutaneous flap has many
advantages, but its disadvantages are also well known.
These are the possibility of abdominal herniation and, in
certain situations, its bulk. To overcome these problems, an
inferior epigastric artery skin flap without rectus abdominis
muscle, pedicled on the muscle perforators and the proximal
inferior deep epigastric artery, have been used in two
patients. A large flap without muscle can survive on a
single muscle perforator.
308
•
• Autologous breast reconstruction using abdominal flaps
18
Mehrara BJ, Santoro TD, Arcilla E, et al. Complications after
microvascular breast reconstruction: experience with
1195 flaps. Plast Reconstr Surg. 2006;118(5):1100–1111.
Moon HK, Taylor GI. The vascular anatomy of rectus
abdominis musculocutaneous flaps based on the deep
superior epigastric system. Plast Reconstr Surg.
1988;82:815–831.
Describes the epigastric arteries as they relate to the TRAM
flap.
Newman MI, Samson MC. The application of laserassisted
indocyanine green fluorescent dye angiography in
microsurgical breast reconstruction. J Reconstr
Microsurg. 2009;25(1):21–26.
Selber JC, Kurichi JE, Vega SJ, et al. Risk factors and
complications in free TRAM flap breast reconstruction.
Ann Plast Surg. 2006;56(5):492–497.
In this retrospective review of 500 free TRAM flap
reconstructions performed by a single surgeon, the authors
summarized the most common complications of TRAM
reconstruction and worked backwards to find risk factors for
poor outcomes. Overall, smoking was the most influential
factor, leading to increased rates of wound infection, skin
flap necrosis and fat necrosis. Obesity was an independent
risk factor for mastectomy flap necrosis. Although limited by
a retrospective design, this article offers nice data to help
predict poor outcomes.
Spear SL. Surgery of the breast: principles and art. Philadelphia:
Lippincott-Raven; 1997.
Describes matching procedures that are available for the
contralateral breast to help with symmetry.
Taylor GI, Daniel RK. The anatomy of several free flap
donor sites. Plast Reconstr Surg. 1975;56(3):243–253.
Uppal RS, Casaer B, Van Landuyt K, et al. The efficacy of
preoperative mapping of perforators in reducing
operative times and complications in perforator flap
breast reconstruction. J Plast Reconstr Aesthet Surg.
2009;62(7):859–864.
Wu LC, Bajaj A, Chang DW, et al. Comparison of donor-site
morbidity of SIEA, DIEP, and muscle-sparing TRAM
flaps for breast reconstruction. Plast Reconstr Surg.
2008;122(3):702–709.
In this study, the authors combined a patient survey with a
retrospective review to assess overall outcomes with
donor-site morbidity following SIEA, DIEP and free TRAM
flap reconstruction. This article suggests decreased
abdominal wall morbidity of the SIEA flap in comparison to
the free TRAM. Although more studies are needed, this
article highlights one of the limitations of the free TRAM
compared with more contemporary options – the donor site.
Although sparing muscle likely limits the effect, by
sacrificing muscle fibers of the rectus, patients are likely to
experience some degree in overall decline of abdominal wall
function which may never return to baseline.
Koshima I, Moriguchi T, Soeda S, et al. Free thin
paraumbilical perforator-based flaps. Ann Plast Surg.
1992;29(1):12–17.
Kroll SS, Baldwin B. A comparison of outcomes using three
different methods of breast reconstruction. Plast
Reconstr Surg. 1992;90:455–462.
Kronowitz SJ, Robb GL. Radiation therapy and breast
reconstruction: a critical review of the literature. Plast
Reconstr Surg. 2009;124(2):395–408.
Radiation therapy can have dramatic effects on both the
surgical field and overall outcomes in breast reconstruction.
In particular, post-reconstruction radiation therapy has been
shown to lead to aesthetic and wound related complications.
This excellent review article summarizes the current
indications for radiation therapy and the existing literature
on its effects on reconstruction. Although no cancer
outcomes are presented showing a clinical impact, this
article summarizes existing literature showing that
reconstruction can compromise radiation delivery. In
addition, the article discusses the “delayed-immediate”
reconstructive algorithm.
Komorowska-Timek E, Gurtner GC. Intraoperative
perfusion mapping with laser-assisted indocyanine
green imaging can predict and prevent complications
in immediate breast reconstruction. Plast Reconstr Surg.
2010;125(4):1065–1073.
Massey MF, Spiegel AJ, Levine JL, et al. Perforator flaps:
recent experience, current trends, and future directions
based on 3974 microsurgical breast reconstructions.
Plast Reconstr Surg. 2009;124:737–751.
Perforator flap breast reconstruction is an accepted surgical
option for breast cancer patients electing to restore their
body image after mastectomy. Since the introduction of the
deep inferior epigastric perforator flap, microsurgical
techniques have evolved to support a 99% success rate for a
variety of flaps with donor sites that include the abdomen,
buttock, thigh, and trunk. Recent experience highlights the
perforator flap as a proven solution for patients who have
experienced failed breast implant-based reconstructions or
those requiring irradiation. Current trends suggest an
application of these techniques in patients previously felt to
be unacceptable surgical candidates with a focus on safety,
aesthetics, and increased sensitization. Future challenges
include the propagation of these reconstructive techniques
into the hands of future plastic surgeons with a focus on the
development of septocutaneous flaps and vascularized lymph
node transfers for the treatment of lymphedema.
Mathes SJ. A rectus abdominis myocutaneous flap to
reconstruct abdominal wall defects. Br J Plast Surg.
1977;30:282–283.
Originally described the epigastric artery as the pedicle
source.
Mathes SJ, Logan SE. The use of a rectus abdominis
myocutaneous flap to reconstruct a groin defect. Br J
Plast Surg. 1984;37:351–353. 5.
©2014, Elsevier Inc. All rights reserved.
Chapter
19
Essential anatomy of the upper extremity
• Palmar skin creases can be used to identify and locate
underlying joints and structures to help plan precise skin
incision placement.
• Kaplan’s cardinal line is an important landmark for
critical internal structures within the hand (Fig. 19. 1/
Box 19.1).
• To avoid contracture in the palm, Littler outlined
imaginary diamond-shaped skin surfaces where a
longitudinal scar should be avoided. These diamond
surfaces can be visualized by noting each joint axis and
the kissing surfaces of the palmar skin in full flexion (Fig.
19.2A,B).
• The palmar fascia consists of resistant, fibrous tissue
arranged in longitudinal, transverse, oblique, and vertical
fibers (Fig. 19.3).
• Longitudinal fibers:
■ Concentrate at the proximal origin of the palmar fascia
at the wrist.
■ Originate from the palmaris longus when present
(80–85% of patients).
■ Make up the fibrous flexor sheath of the digits.
■ Attach to the volar plate and intermetacarpal
ligaments at the level of the metacarpal heads.
• Transverse fibers:
■ Concentrated in the midpalm and the web spaces.
■ Make up the transverse palmar ligament.
■ Act as pulleys for the flexor tendons proximal to the
level of the digital pulleys.
• Vertical fibers:
■ Superficial to the longitudinal and transverse fibers,
vertical fibers travel to the palm skin dermis (Fig. 19.4).
■ Deep to the palmar fascia, they coalesce into septae
and form eight individual compartments for the flexor
tendons to each digit, and the neurovascular bundles
together with the lumbrical muscles (Fig. 19.5).
• In the fingers, there are two important bands of fascia
which help contain and protect the ulnar and radial
This chapter was created using content from
Neligan & Chang, Plastic Surgery 3rd edition,
Volume 6, Hand and Upper Extremity, Chapter 1,
Anatomy and biomechanics of the hand, James
Chang, Francisco Valero-Cuevas, Vincent R. Hentz
and Robert A. Chase.
SYNOPSIS
■ Introduction – history to anatomy and biomechanics of the hand
■ Skin, subcutaneous tissue, and fascia
■ Bones and joints
• Hand elements
• The wrist
• Joint motion
• The thumb
■ Muscles and tendons
• Extrinsic extensors
• Pronators and supinators
• Extrinsic flexors
• The retinacular system
• Intrinsic muscles
■ Blood supply
■ Peripheral nerves
Skin, subcutaneous tissue, and fascia
• Dorsal skin of the hand is thin and pliable and anchored
to the deep investing fascia only by loose, areolar tissue.
• Palmar skin has a thick dermal layer and a heavily
cornified epithelial surface that is held tightly to the thick
fibrous palmar fascia by diffusely distributed vertical
fibers.
• The skin of the palm is laden with a high concentration
of specialized sensory end organs and sweat glands.
310
•
• Essential anatomy of the upper extremity
19
iii. The index digit: independence of action within the
range of motion allowed by its joints, ligaments, and
the action of three intrinsic and four extrinsic
muscles.
iv. The third, fourth, and fifth digits with the fourth and
fifth metacarpals: functions as a stabilizing vise to
grasp objects for manipulation by the thumb and
index finger, or in concert with the other hand units
in powerful grasp (Fig. 19.7).
• The distal row of carpal bones forms a solid architectural
arch with the capitate bone as a keystone. Together with
the 2nd and 3rd metacarpals they form the fixed unit of
the hand.
• As a stable foundation, this unit creates a supporting base
for the three other mobile units: the first metacarpal, the
fourth metacarpal, and the fifth metacarpal.
• The first metacarpal moves through a wide range of
motion as a result of loose capsular ligaments and
the shallow saddle articulation between it and the
trapezium.
• Motion is stabilized by the capsular ligaments, including
the volar beak ligament, and by its attachment to the
fixed hand axis through the adductor pollicis, the first
dorsal interosseous, and the fascia and skin of the first
web space.
• The mobile fourth and fifth metacarpal heads move
dorsally and palmarly in relation to the central hand axis
by limited mobility at their carpometacarpal joints.
• These metacarpal heads are tethered to the central
metacarpals by the intermetacarpal ligaments (unite
adjacent metacarpophalangeal volar plates).
• The third metacarpophalangeal joint acts as the anatomic
center of the hand. With the fingers fully abducted,
the tips form radii of equal length from this point. The
same radius projected proximally falls at the wrist joint
(Fig. 19.8).
• The most important single motor operating the central
hand beam at the wrist level is the extensor carpi radialis
brevis, which works against gravity, positioning the
pronated hand into extension.
The wrist
• The wrist joint has a multi-articulated architecture that
creates a potentially wide range of motion in flexion,
extension, radial deviation, ulnar deviation, and
circumduction (Fig. 19.9).
• The distal radioulnar joint (DRUJ) allows pronation and
supination of the hand as the radius rotates around the
head of the ulna (Fig. 19.10).
• The proximal row of carpal bones (scaphoid, lunate,
triquetrum, pisiform) articulates with the distal radius
and ulna, providing the ability to flex and extend the
hand and perform radial and ulnar deviation.
• All four of the bones in the distal carpal row present
articular surfaces for junction with the metacarpals.
• The principal articulation of the carpus is with the distal
surface of the radius at the radiocarpal joint.
digital arteries and nerves: Grayson’s ligaments and
Cleland’s ligaments.
■ Grayson’s ligaments are volar to the neurovascular
bundles and are quite flimsy.
■ Cleland’s ligaments are dorsal to the neurovascular
bundles and are much stouter (Fig. 19.6).
Bones and joints
• The hand skeleton is divisible into four elements:
i.
The fixed unit of the hand: the second and third
metacarpals and the distal carpal row.
ii.
The thumb and its metacarpal: displays a wide range
of motion at the carpometacarpal joint allowed by the
joint, ligaments and insertion of five intrinsic and
four extrinsic muscles.
Figure 19.1 Kaplan’s cardinal line, along lines from the ulnar aspect of the middle
finger and the ulnar aspect of the ring finger. Point A corresponds with the motor
branch of the median nerve and point B with the motor branch of the ulnar nerve.
Hook of hamate
A
B
Kaplan’s cardinal line
Pisiform
BOX 19.1 Clinical pearl: Kaplan’s cardinal line
Hand anatomist Emanuel Kaplan described specific surface lines
that would aid surgeons in locating key structures in the palm of the
hand. The cardinal line has often been misquoted; therefore we
refer to Kaplan’s classic hand text: Functional and Surgical Anatomy
of the Hand. Kaplan’s cardinal line is drawn from the apex of the
first web space to the distal edge of the pisiform bone (Fig. 19.1).
Two longitudinal lines are drawn from the ulnar aspect of the middle
finger and the ulnar aspect of the ring finger. These will cross the
cardinal line. The intersection of the cardinal line and the
longitudinal line from the ulnar side of the middle finger corresponds
to the motor branch of the median nerve. The intersection of the
cardinal line and the longitudinal line from the ulnar side of the ring
finger corresponds to the hook of the hamate. The motor branch of
the ulnar nerve is found on the cardinal line, equidistant between
the hamate and pisiform. See Kaplan’s original text for additional
surface markings.
311
The wrist
Figure 19.2 (A,B) Schematic representation of the joint axes. The longitudinal dimensions in the midpalmar and
middorsal aspect of the digits change maximally. The midaxial line through the three joint axes does not change in
length with flexion and extension. Palmar incisions placed longitudinally produce contracture if they pass across the
palmar diamonds delineated by lines joining the joint axes (after Littler). Transverse incisions avoid the occurrence
of flexion scar contractures. The same principle applies at the wrist. (Redrawn after Chase RA. Atlas of Hand Surgery.
vol 1. Philadelphia: WB Saunders; 1973.)
A
b
a
d
c
B
• With an articular surface that slopes in several planes,
fractures of the distal radius frequently result in a loss of
the normal dorsal-to-palmar tilt of the articular surface
leading to a change in the biomechanical properties of the
wrist joint and degenerative arthritis.
• The relationship of the length of the radius to the length
of the ulna is fairly constant in individuals, and is termed
ulnar variance.
• Normal ulnar variance: the distal ulna completes the
curve of the articular surface of the radius.
312
•
• Essential anatomy of the upper extremity
19
Figure 19.3 Superficial dissection of the palm, showing orientation of the palmar fascia. Reprinted with permission from © Elsevier Inc. All Rights
Reserved.
Palmaris longus tendon
Branch of superficial
radial nerve to skin of
lateral thenar area
Thenar muscles
Palmar branch of
median nerve
Anterior (palmar) views
Palmar aponeurosis
Transverse fasciculi
Palmar digital arteries and nerves
Superficial transverse metacarpal ligaments
Palmaris brevis
muscle (reflected)
Palmar branch of ulnar nerve
Superficial branch of ulnar nerve
Ulnar artery
Palmaris brevis muscle
Hypothenar muscles
Palmar aponeurosis
Pisiform
Deep palmar branch of ulnar artery and deep
branch of ulnar nerve
Palmar carpal ligament
(thickening of deep
antebrachial fascia
continuous with
extensor retinaculum)
Recurrent
(motor)
branch of
median
nerve to
thenar
muscles
Minute fasciculi
attach palmar
aponeurosis to dermis
Palmar digital
nerves from
superficial
branch of ulnar
nerve to 5th and
medial half of
4th fingers
313
The wrist
Extrinsic carpal ligaments
• Anchor the proximal carpal row to the radius.
• Stout palmar ligaments arise primarily from the radius,
and from the ulna and the palmar portion of the
triangular fibrocartilage complex (TFCC).
• The TFCC separates the distal end of the ulna from the
ulnar-sided carpal bones and serves to suspend the distal
ulna to the radius at the distal radioulnar joint.
• The dorsal extrinsic radiocarpal ligament complex is thin
and is primarily a condensation of capsular tissues,
except for two stout structures: the dorsal intercarpal
ligament (joins the distal pole of the scaphoid and the
triquetrum), and the dorsal radiocarpal ligament (passes
from radius to triquetrum).
Intrinsic carpal ligaments
• Broad structures that link one carpal bone to another,
either within the proximal or distal row, or link one
carpal row to the other.
• The two most significant intrinsic ligaments are the
scapholunate ligament and the lunotriquetral ligament.
• The scapholunate ligament: A U-shaped structure that
anchors the scaphoid to the lunate, allowing these two
carpal bones to move in synchrony.
■ Subdivided into three regions: dorsal, proximal, and
palmar.
■ The dorsal region is thick and controls scapholunate
stability.
■ The proximal portion, composed mainly of
fibrocartilage, and the palmar region, with thin and
obliquely oriented fibers are less important for
stability.
• The lunotriquetral ligament: anchors the lunate to the
triquetrum.
■ Also composed of dorsal, proximal, and palmar
portions.
Hand/joint motion
• Metacarpophalangeal (MCP) joint.
• Motion in the fingers ranges from 0 to 90°.
• Lateral motion is limited by the rein-like collateral
ligaments (Fig. 19.13).
• At the MCP joint, if the collateral ligaments are sacrificed,
the interossei remain the sole source of lateral stability.
• The proximal interphalangeal joint (PIP):
■ Can be pushed to 110° of flexion, but extension usually
cannot be carried beyond 5° of hyperextension because
of the volar plate.
■ The medial and lateral collateral ligaments, also part of
the joint capsule, are fixed in a manner that allows no
medial or lateral deviation of the joint in any position.
■ Unlike the MCP joints, the collateral ligaments of the
PIP and/or DIP cannot be sacrificed without creating a
lateral instability that is curable only by fusion.
■ The hinge-shape of the articular joint surface also
strongly contributes to this stability in lateral motion.
• Ulnar negative variance: the end of the ulna falls short of
this curvature.
■ Higher incidence of Kienbock’s disease (avascular
necrosis of the lunate).
• Ulnar positive variance: the ulna extends distal to this
imaginary extension.
■ If variance greater than 2–3 mm, associated with ulnar
impaction (Fig. 19.11).
• Gilula’s lines: denote normal extracarpal and intracarpal
architecture. Any disruption of these lines is a sign of
carpal abnormality.
• Greater arc: a line that follows the proximal articular
contours of the proximal row of carpal bones
circumscribing a smooth arc (Fig. 19.12).
• Lesser arc: a line between the proximal and distal row of
carpal bones circumscribing another smooth arc.
• The scaphoid and lunate form the primary articulation
with the distal radius.
• The scaphoid also articulates with the distal carpal row
through attachments to the trapezium and trapezoid.
• The triquetrum articulates with the lunate in the proximal
row, and with the hamate across the midcarpal joint.
• The pisiform is essentially a floating bone, unimportant
for carpal stability.
Wrist motion
• A product of the sums of the movements of the carpal
bones in various planes and degrees of rotation relative
to one another.
• The motion of any one carpal bone is a consequence of
several factors:
• The contour of the bone and the arrangements of its
articular surfaces.
• The degree of freedom afforded by the intrinsic ligaments
(ligaments originating from one carpal bone and inserting
on another carpal bone).
• The degree of freedom afforded by the extrinsic ligaments
(ligaments arising from the radius or ulna and attaching
to a carpal bone or bones).
• The mechanics of the wrist rely heavily upon the
proximal carpal row flexing or extending to accommodate
movement of the fixed distal carpus.
Figure 19.4 The palmar fascia with its longitudinal, transverse, and vertical fibers.
The longitudinal fibers take origin in the palmaris longus (when present). Transverse
fibers are concentrated in the distal palm supporting the web skin and in the midpalm
as the transverse palmar ligament. Vertical fibers extend superficially as multiple, tiny
tethering strands to stabilize the thick palmar skin. The deep vertical components
concentrate in septa between the longitudinally oriented structures in the fingers.
Redrawn after McCarthy JG. Plastic Surgery. Philadelphia: WB Saunders; 1990.
Vertical fibers
(cont’d)
314
•
• Essential anatomy of the upper extremity
19
Figure 19.5 These deep palmar and midpalmar axial views of the hand reinforce the concept of distinct anatomic compartments separated by fascia. (Reprinted with
permission from © Elsevier Inc. All Rights Reserved.)
Pronator quadratus muscle
Flexor carpi radialis tendon
Flexor retinaculum (transverse carpal ligament) (reflected )
Flexor digitorum profundus tendons
Tendinous sheath of flexor pollicis
longus (radial bursa)
Fascia of adductor pollicis muscle
Thenar space
(deep to flexor tendon
and 1st lumbrical muscle)
Annular and cruciform parts
(pulleys) of fibrous sheath over
synovial sheath of finger
(Synovial) tendon
sheath of finger
Lumbrical muscles in fascial sheaths
(cut and reflected )
Flexor pollicis longus
tendon in tendon
sheath (radial bursa)
Common
flexor sheath
(ulnar bursa)
Flexor digitorum
superficialis tendons
Common flexor sheath
(ulnar bursa) (opened)
Lumbrical muscles in
fascial sheaths
Midpalmar space
(deep to flexor tendons
and lumbrical muscles)
Fibrous and synovial (tendon)
sheaths of finger (opened)
Flexor digitorum superficialis
tendon
Flexor digitorum profundus
tendon
Common palmar digital
artery and nerve
Lumbrical muscle
in its fascial sheath
Flexor tendons to 5th
digit in common flexor
sheath (ulnar bursa)
Dorsal fascia of hand
Tendinous sheath of flexor pollicis longus (radial bursa)
Septa forming canals
Profundus and superficialis flexor tendons to 3rd digit
Septum between midpalmar and thenar spaces
Thenar space
Extensor pollicis
longus tendon
Adductor pollicis muscle
Palmar interosseous fascia
Palmar interosseous muscles
Dorsal interosseous muscles
Extensor tendons
Midpalmar space
Palmar aponeurosis
Hypothenar muscles
Dorsal interosseous fascia
Dorsal subaponeurotic space
Dorsal subcutaneous space
315
The wrist
Figure 19.6 The components of the digital fascia that help to anchor the axial
plane skin are Grayson’s ligaments palmar to the neurovascular bundles and
Cleland’s ligaments dorsal to the bundles. (Redrawn after McCarthy JG. Plastic
Surgery. Philadelphia: WB Saunders; 1990.)
Grayson’s
ligament
Neurovascular
bundle
Natatory ligament
Pretendinous band
Common digital
artery
Cleland’s ligament
Lateral digital sheet
Spiral band
Transverse fibers of
palmar aponeurosis
Figure 19.7 Exploded view of the functional elements of the hand: (1) the thumb
and its metacarpal with a wide range of motion at the carpometacarpal joint; (2) the
index digit with independence of action in several planes; (3) the third, fourth, and
fifth digits with the fourth and fifth metacarpals; (4) the fixed unit consisting of the
carpals with the fixed transverse carpal arch and the second and third metacarpals
forming a fixed longitudinal arch. (Redrawn after McCarthy JG. Plastic Surgery.
Philadelphia: WB Saunders; 1990.)
Figure 19.8 When the adaptive arch is semicircular, the fingers converge in a
cone over the anatomic center of the hand – the long finger metacarpophalangeal
joint. (Redrawn after McCarthy JG. Plastic Surgery. Philadelphia: WB Saunders;
1990.)
316
•
• Essential anatomy of the upper extremity
19
Figure 19.9 Bony anatomy of the wrist and hand. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Carpal
bones
Lunate
Triquetrum
Pisiform
Capitate
Hamate
Hook
Base
Shafts
Head
Base
Shafts
Head
Base
Shafts
Head
Base
Shafts
Tuberosity
Head
Right hand:
anterior (palmar) view
Sesamoid
bones
Lunate
Scaphoid
Capitate
Trapezoid
Trapezium
Triquetrum
Hamate
Base
Shafts
Head
Base
Shafts
Head
Base
Shafts
Head
Base
Shafts
Tuberosity
Head
Right hand:
posterior (dorsal) view
Carpal bones
Metacarpal bones
Proximal phalanges
Middle phalanges
Distal
phalanges
Carpal
bones
Metacarpal bones
Proximal phalanges
Middle phalanges
Distal
phalanges
Carpal
bones
1
2
3
4
5
1
2
3
4
5
Scaphoid
Tubercle
Trapezium
Tubercle
Trapezoid
317
The wrist
Figure 19.10 Relationship of the radius and ulna at the proximal and distal radioulnar joints. (Reprinted with permission from © Elsevier Inc. All
Rights Reserved.)
Olecranon
Head
Neck
Radial tuberosity
Radius
Anterior surface
Anterior border
Interosseous border
Interosseous
membrane
Styloid process
Styloid process
of ulna
Radius
Ulna
Ulnar notch
of radius
Styloid process
Styloid
process
Area for scaphoid bone
Area for lunate bone
Carpal articular suface
Trochlear notch
Coronoid process
Radial notch of ulna
Ulnar tuberosity
Oblique cord
Oblique cord
Ulnar tuberosity
Ulna
Ulna
Lateral surface
Posterior border
Posterior surface
Anterior border
Anterior surface
Interosseous
membrane
Interosseous
border
Dorsal tubercle
Styloid process
Radius
Right radius and ulna
in supination: anterior view
Right radius and
ulna in pronation:
anterior view
Area for extensor
pollicis brevis and
abductor pollicis
longus muscles
Groove for extensor
digitorum and extensor
indicis muscles
Groove for extensor
pollicis longus muscle
Groove for extensor
carpi radialis longus
and brevis muscles
Coronal section of
radius demonstrates
how thickness of
cortical bone of
shaft diminishes
to thin layer over
cancellous bone
at distal end
318
•
• Essential anatomy of the upper extremity
19
Figure 19.11 X-ray of ulnar positive variance: this patient has ulnar-sided wrist
pain due to ulnar impaction syndrome.
Figure 19.12 X-ray: Gilula’s lines showing the greater arc and lesser arc of the
carpal bones. (From Hertz VR, Chase RA. Hand Surgery: A clinical Atlas.
Philadelphia: WB Saunders; 2001.)
Figure 19.13 The true collateral ligaments of the metacarpophalangeal joint are
loose in extension but tight in flexion of the joint as a result of the cam effect of the
metacarpal head in relationship to the proximal phalanx. This accounts for the lack
of lateral mobility of the joint when it is flexed. (Redrawn after Chase RA. Atlas of
Hand Surgery, vol. 1. Philadelphia: WB Saunders; 1973.)
Maximum
mobility
Minimum
mobility
Hyperextension
45° Position of rest
Flexion
• The distal interphalangeal (DIP) joints:
■ Can be pushed into about 90° of flexion before they are
limited by the dorsal joint capsule and extensor
mechanism.
■ Extend to 30° of hyperextension.
■ As in the PIP joint, there is no lateral mobility in these
joints with the collateral ligaments intact.
The thumb
• Made up of two phalanges, the metacarpal, and the
trapezium.
• It differs from the other digits by virtue of its two named
phalanges (rather than three).
• From a functional point of view, the thumb metacarpal
can be compared to a proximal phalanx and the
trapezium to a grossly foreshortened metacarpal
(Fig. 19.14).
• The thumb MCP joint has the greatest degree of freedom
of any in the digital rays which is attributable to the
double saddle configuration between the base of the first
metacarpal and the trapezium which allows three degrees
of motion:
■ flexion–extension
■ abduction–adduction
■ medial rotation–lateral rotation.
• The base of the first metacarpal has a concavity that is
slightly exaggerated on the ulnar volar side by a
protrusion or “beak” for insertion of the anterior oblique
carpometacarpal ligament (“volar beak” ligament).
• Volar beak ligament: important in stabilizing the first
CMC joint. Clinically, it retains the fragment of bone
fractured free from the base of the metacarpal in a
Bennett’s fracture. Also, in advanced CMC joint arthritis
it weakens and attenuates allowing radial subluxation.
• There is also a stout intermetacarpal ligament between
the base of the first metacarpal and the adjacent base of
319
Muscles and tendons
Figure 19.14 The osteoarticular column of the thumb as compared with that of a
finger. The trapezium in this comparison is the equivalent of a foreshortened
metacarpal, and the metacarpotrapezial joint of the fingers. FDP, flexor digitorum
profundus; FDS, flexor digitorum superficialis. (Redrawn after Chase RA. Anatomy of
the thumb. In: Strickland J (ed.) The Thumb. Edinburgh: Churchill Livingstone;
1989.)
Hinge
Index finger
Thumb
DP
PP
MC
MC
PP
MP
DP
Trapezium
Scaphoid
Capitate
Hinge
Wide ROM
Limited ROM
the second metacarpal that is also important to
prevention of radial subluxation of the
metacarpotrapezial joint.
Muscles and tendons
Extrinsic extensors
• Extensor muscles lie on the dorsum of the forearm and
hand and are innervated by the radial nerve (Figs
19.15–19.18).
• The extensor retinaculum prevents bowstringing of
tendons across the wrist (Fig. 19.19).
• Six extensor compartments exist:
1. Abductor pollicis longus and extensor pollicis brevis.
2. Extensor carpi radialis longus and extensor carpi
radialis brevis.
3. Extensor pollicis longus.
4. Extensor digitorum communis and extensor indicis
proprius.
5. Extensor digiti minimi.
6. Extensor carpi ulnaris.
• Extension of the phalanges of the fingers and thumb is
dependent both on long extensors at the MCP joints and
on an interplay between the long extensors and intrinsic
muscles at the IP joints.
• The extensor digitorum is a series of tendons with a
common muscle belly that enters into the central extensor
of each of the fingers. There are intertendinous bridges
between these separate tendons over the dorsum of the
hand (juncture).
• Independent long extensor power is also supplied to the
index finger through the extensor indicis and to the little
finger through the extensor digiti minimi.
■ This independent extensor lies ulnar to the extensor
digitorum communis tendon.
• Each of the three extrinsic muscles to the thumb on its
extensor surface inserts on one of the thumb bones.
Pronators and supinators
• The major pronators and supinators of the hand are the
pronator teres, pronator quadratus, and supinator (with
assistance from the biceps brachii), respectively (Fig. 19.20).
Extrinsic flexors
• Flexion of the phalanges into the palm is a complicated
motion representing the sum of actions of the long flexors
(profundus and superficialis) and long extensors
(extensor digitorum, extensor digiti minimi, and extensor
indicis), modified and enhanced by the intrinsic muscles
(interossei and lumbricals) (Figs 19.21–19.25).
• The long flexors to the fingers are responsible for flexion
of the interphalangeal joints and are supplements to
active flexion of the metacarpophalangeal joints and the
wrist joint.
• The flexors are located on the volar side of the forearm
and wrist and are innervated by the median nerve, except
the flexor carpi ulnaris, and the flexor digitorum
profundus to the ring and small fingers which are
innervated by the ulnar nerve (see Figs 19.21–19.25).
• The flexor digitorum superficialis tendon lies palmar
(superficial) to the profundus tendon in the palm. It splits
at the level of the proximal phalanx, wraps around and
decussates behind the profundus to insert on the middle
phalanx.
• The flexor digitorum profundus perforates the flexor
digitorum superficialis to run superficial along the length
of the proximal and middle phalanges to insert at the
base of the distal phalanx.
• The flexor digitorum profundus of the index finger is
unique in that it has an independent muscle belly.
• The tendon–muscle unit has an effect on each joint it
crosses, which is altered by the positioning of the other
joints in the linkage system. Thus, the influence of the
tendon on one joint in the system is augmented by the
function of its antagonists at each of the other joints it
crosses. This is the simplified definition of synergistic
function.
• Synergistic and antagonistic groups of muscles in hand
function must be considered when functional substitution
by tendon transfers is contemplated.
■ Examples of such natural synergism are the united
functions of the wrist flexors and digital extensors or
the wrist extensors and digital flexors.
(cont’d)
320
•
• Essential anatomy of the upper extremity
19
Figure 19.15 The anatomy of the extensor muscles: superficial to deep. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Superior ulnar collateral artery
(anastomoses distally with
posterior ulnar recurrent artery)
Ulnar nerve
Medial epicondyle of humerus
Olecranon of ulna
Anconeus muscle
Flexor carpi ulnaris muscle
Extensor carpi ulnaris muscle
Triceps brachii muscle
Brachioradialis muscle
Extensor carpi radialis longus muscle
Common extensor tendon
Extensor carpi radialis brevis muscle
Extensor digitorum muscle
Extensor digiti minimi muscle
Abductor pollicis longus muscle
Extensor pollicis brevis muscle
Extensor pollicis longus tendon
Extensor carpi radialis brevis tendon
Extensor carpi radialis longus tendon
Superficial branch of radial nerve
Abductor pollicis longus tendon
Extensor pollicis brevis tendon
Extensor pollicis longus tendon
Anatomical snuffbox
1
2
3
4
5
6
Extensor carpi ulnaris tendon
Extensor digiti minimi tendon
Extensor digitorum tendons
Extensor indicis tendon
5th metacarpal bone
Dorsal branch of ulnar nerve
Extensor retinaculum
(compartments numbered)
321
Muscles and tendons
Figure 19.16 The anatomy of the extensor muscles: superficial to deep. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Middle collateral branch of
deep brachial artery
Lateral intermuscular septum
Brachioradialis muscle
Extensor carpi radialis longus muscle
Lateral epicondyle of humerus
Common extensor tendon (partially cut )
Extensor carpi radialis brevis muscle
Supinator muscle
Posterior interosseous nerve
Pronator teres muscle (slip of insertion)
Radius
Posterior interosseous nerve
Abductor pollicis longus muscle
Extensor pollicis brevis muscle
Extensor carpi radialis brevis tendon
Extensor carpi radialis longus tendon
1
2
3
4
5
6
Radial artery
1st metacarpal bone
2nd metacarpal bone
1st dorsal
interosseous muscle
5th metacarpal bone
Extensor retinaculum
(compartments numbered)
Extensor digitorum tendons (cut )
Extensor digiti minimi tendon (cut )
Extensor carpi ulnaris tendon (cut )
Anterior interosseous artery (termination)
Extensor indicis muscle
Extensor pollicis longus muscle
Ulna
Posterior interosseous artery
Recurrent interosseous artery
Flexor carpi ulnaris muscle
Anconeus muscle
Olecranon of ulna
Triceps brachii tendon (cut )
Medial epicondyle of humerus
Posterior ulnar recurrent artery
Ulnar nerve
Medial intermuscular septum
Inferior ulnar collateral
(posterior branch)
Superior ulnar collateral
Branches of
brachial artery
322
•
• Essential anatomy of the upper extremity
19
Figure 19.17 The anatomy of the extensor muscles: superficial to deep. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Medial
epicondyle
Note: Anconeus muscle not shown
because it is extensor of elbow
Medial epicondyle
Olecranon
Lateral epicondyle
Common
extensor
tendon
Extensor
digitorum
and extensor
digiti minimi
(cut away)
Interosseous
membrane
Radius
Ulna
Olecranon
Ulna
Extensors of wrist
Extensor carpi
radialis longus
Extensor carpi
radialis brevis
Extensor carpi ulnaris
Extensors of digits
(except thumb)
Extensor digitorum
Extensor digiti minimi
Extensor indicis
Extensors of thumb
Abductor pollicis longus
Extensor pollicis brevis
Extensor pollicis longus
Extensor digitorum
and extensor digiti
minimi tendons (cut)
Extensor
indicis
tendon
Common
extensor
tendon
Lateral
epicondyle
Right forearm:
posterior
(dorsal) views
323
Muscles and tendons
Figure 19.18 The extensor mechanism of the fingers. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Insertion of central band of extensor
tendon to base of middle phalanx
Triangular aponeurosis
Slips of long
extensor tendon
to lateral bands
Extensor
expansion
(hood)
Long extensor
tendon
Interosseous muscles
Metacarpal bone
Posterior
(dorsal)
view
Insertion on extensor tendon
to base of distal phalanx
Lateral bands
Interosseous
tendon slip
to lateral band
Lumbrical muscle
Part of interosseous tendon
passes to base of proximal
phalanx and joint capsule
Extensor expansion (hood)
Long extensor tendon
Metacarpal bone
Interosseous muscles
Lumbrical muscle
Flexor digitorum
profundus tendon
Lateral band
Central band
Insertion of extensor tendon
to base of middle phalanx
Insertion of extensor
tendon to base
of distal phalanx
Finger in
extension:
lateral view
Collateral
ligaments
Vinculum
breve
Vincula
longa
Flexor digitorum
superficialis tendon
Collateral ligament
Extensor tendon
Insertion of small deep slip of extensor
tendon to proximal phalanx and joint capsule
Attachment of interosseous muscle to
base of proximal phalanx and joint capsule
Insertion of lumbrical
muscle to extensor tendon
Finger in flexion:
lateral view
Palmar ligament (plate)
Flexor digitorum
superficialis tendon (cut)
Collateral ligaments
Flexor digitorum
profundus tendon (cut)
Palmar ligament (plate)
Interosseous muscles
Lumbrical muscle
Note: Black arrows indicate
pull of long extensor tendon;
red arrows indicate pull
of interosseous and
lumbrical muscles; dots
indicate axis of
rotation of joints
324
•
• Essential anatomy of the upper extremity
19
Figure 19.19 The extensor retinaculum and extensor compartments. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Posterior (dorsal) view
Extensor carpi ulnaris – Compartment 6
Extensor digiti minimi – Compartment 5
Extensor digitorum
Extensor indicis
Extensor pollicis longus – Compartment 3
Extensor carpi radialis brevis
Extensor carpi radialis longus
Abductor pollicis longus
Extensor pollicis brevis
Radial artery in anatomical snuffbox
Dorsal interosseous muscles
Compartment 4
Compartment 2
Compartment 1
Extensor retinaculum
Abductor digiti
minimi muscle
Intertendinous connections
Transverse fibers of
extensor expansions (hoods)
Cross section of most distal portion of forearm
Extensor retinaculum
Extensor pollicis longus – Compartment 3
Extensor carpi
radialis brevis
Extensor carpi
radialis longus
Compartment 2
Extensor
pollicis brevis
Abductor
pollicis longus
Compartment 1
Extensor digitorum and
extensor indicis
Extensor
digiti minimi
Extensor
carpi
ulnaris
Compartment 4
Compartment 5
Compartment 6
Ulna
Radius
Plane of cross section
shown below
6
5
4
3
2
1
325
Muscles and tendons
Figure 19.20 The forearm pronators and supinators. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Right forearm: anterior view
Supinated position
Pronated position
Lateral epicondyle
Medial epicondyle
Lateral epicondyle
Medial epicondyle
Supinator
Pronator teres
Ulna
Radius
Ulna
Radius
Pronator quadratus
326
•
• Essential anatomy of the upper extremity
19
Figure 19.21 The anatomy of the flexor muscles – superficial to deep. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Note: Brachioradialis muscle not shown
because it is flexor of elbow
Lateral epicondyle
Medial epicondyle
Common flexor tendon
Flexor carpi radialis
Palmaris longus
Flexor carpi ulnaris
Radius
Ulna
Pisiform
Hook of hamate
Palmar aponeurosis (cut)
Right forearm:
anterior (palmar) view
327
Muscles and tendons
Figure 19.22 The anatomy of the flexor muscles – superficial to deep. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Ulnar nerve
Median nerve
Brachial artery
Medial intermuscular septum
Pronator teres muscle (humeral head)
(cut and reflected )
Flexor carpi radialis and palmaris
longus tendons (cut )
Flexor digitorum superficialis
muscle (humeroulnar head)
Medial epicondyle
Biceps brachii muscle
Brachialis muscle
Lateral antebrachial cutaneous nerve (cut )
(from musculocutaneous nerve)
Radial nerve
Deep branch
Superficial branch
Biceps brachii tendon
Radial recurrent artery
Radial artery
Supinator muscle
Brachioradialis muscle
Pronator teres muscle (cut )
Flexor digitorum superficialis
muscle (radial head)
Anterior ulnar recurrent artery
Ulnar artery
Common interosseous artery
Pronator teres muscle (ulnar head) (cut )
Anterior interosseous artery
Flexor carpi ulnaris muscle
Flexor digitorum superficialis muscle
Ulnar artery
Ulnar nerve and dorsal branch
Median nerve
Palmar branches of median and ulnar nerves (cut )
Pisiform
Deep palmar branch of ulnar artery
and deep branch of ulnar nerve
Flexor retinaculum
(transverse carpal ligament)
Superficial branch of ulnar nerve
Superficial palmar branch
of radial artery
Flexor carpi radialis
tendon (cut )
Palmar carpal ligament
(continuous with extensor
retinaculum) with palmaris
longus tendon (cut and reflected )
Flexor pollicis longus muscle
328
•
• Essential anatomy of the upper extremity
19
Figure 19.23 The anatomy of the flexor muscles – superficial to deep. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Medial epicondyle
Lateral epicondyle
Common flexor tendon
Coronoid process
Interosseous membrane
Radius
Medial epicondyle
Lateral epicondyle
Coronoid process
Interosseous
membrane
Radius
Flexor digitorum superficialis
Flexor digitorum profundus
Flexor pollicis longus
Ulna
Radius
Radius
Flexor digitorum superficialis
tendons (cut away)
Ulna
Right forearm:
anterior (palmar) views
329
The retinacular system
and inserts on the middle one-third of the radial
palmar surface of the middle phalanx.
• Four or five discrete annular pulleys and three cruciate
bands are ordinarily present in the fingers (Fig. 19.27).
■ The most proximal pulley (A1) begins 0.5 cm proximal
to the MCP joint.
■ A2 is located just distal to A1, is the largest pulley, and
extends to nearly the proximal one-half of the proximal
phalanx.
■ The first cruciform band (Cl) lies distal to A2 and well
proximal to the PIP joint.
■ A3 lies over the PIP joint, arising from its volar plate.
■ The second cruciate ligament (C2) is at the base of the
middle phalanx.
■ A4 lies over the middle one-third of the middle
phalanx.
■ The third cruciate (C3) is just distal to A4.
■ A5 is often possible to identify as a thickening of the
sheath over the DIP joint.
• The relationship of the tendon to the joint axes is
maintained by retinacular structures, or pulleys. This
prevents the bowstring effect, which would allow the
tendon to move away from the joint axis, changing the
moment arm and therefore the force exerted at that joint
by the flexor tendon.
The retinacular system
• Transverse carpal ligament (Fig. 19.26A–D):
■ Bridges the volar surface of the carpals from the
pisiform and hook of the hamate ulnarly to the
scaphoid tubercle and trapezium radially.
■ Confines the nine extrinsic flexor tendons and the
median nerve within the carpal tunnel.
■ Prevents bowstringing of the flexor tendons at the
wrist.
• Three pulleys housing the flexor pollicis longus within
the thumb are regularly present.
■ The proximal annular pulley: at the level of the MCP
joint arising from the volar plate and base of the
proximal phalanx.
■ The distal annular pulley: over the volar plate of the
interphalangeal joint.
■ Oblique pulley: located between the two, it originates
proximally on the ulnar side of the middle phalanx
Figure 19.24 The anatomy of the flexor muscles – superficial to deep. (Reprinted
with permission from © Elsevier Inc. All Rights Reserved.)
0
0.5 Resting length
Resting length
1.5 Resting length
0.5 Fmax
Fmax
Muscle fiber length (normalized to resting fiber length)
Maximal isometric force
(for a given activation level)
Figure 19.25 The anatomy of the flexor muscles – superficial to deep. (Reprinted
with permission from © Elsevier Inc. All Rights Reserved.)
Relative shortening velocity
(resting lengths/s)
Percent maximal isometric force
Shortening
Lengthening
100%
180%
-0.8
0.0
0.8
Figure 19.26 The flexor tendon pulley system for fingers and thumb. (Redrawn
after Chase RA. Atlas of Hand Surgery, vol II. Philadelphia: WB Saunders; 1984.)
A
C
D
B
Annular
Oblique
A1
A2
C1
A3
C2
A4 C3 A5
Annular
Thumb pulleys
Finger pulleys
A1
A2
C1
A3
C2
A4
C3
A5
Transverse carpal
ligament
330
•
• Essential anatomy of the upper extremity
19
Figure 19.27 Orientation of the flexor tendon sheaths, flexor tendons, and pulleys. (Reprinted with permission from © Elsevier Inc. All Rights
Reserved.)
Thenar space
Midpalmar space
(Synovial) tendon
sheaths of fingers
Usual arrangement
Intermediate bursa
(communication
between common
flexor sheath [ulnar
bursa] and tendinous
sheath of flexor pollicis
longus [radial bursa])
Flexor digitorum
profundus tendons
1st and 2nd lumbrical muscles
(unipennate)
Common variation
3rd and 4th lumbrical muscles
(bipennate)
Flexor digitorum
superficialis tendons (cut)
Lumbrical muscles: schema
Palmar ligaments (plates)
A2
C2
A3
C3
A4
C4
A5
Tendinous sheath of flexor
pollicis longus (radial bursa)
Common flexor sheath
(ulnar bursa)
Lumbrical muscles
(in fascial sheaths)
(Synovial) tendon sheath
Tendons of
flexor digitorum
superficialis
and profundus
muscles
Note: Flexor digitorum superficialis and
profundus tendons encased in synovial
sheaths are bound to phalanges by fibrous
digital sheaths made up of alternating
strong annular (A) and weaker cruciform (C)
parts (pulleys).
Camper chiasm
A1
C1
331
Blood supply
• Knowledge of the anatomy of the synovial sheaths and
potential anatomic spaces in the hand is essential for
proper diagnosis and treatment of serious hand
infections. Infection starting in the digital synovial
sheaths may extend proximally to the deep palmar
spaces.
Intrinsic muscles
• Intrinsic muscles arise and insert within the hand (Figs
19.30, 19.31). They can be divided into four groups:
■ The thenar muscles.
■ Abductor pollicis brevis, flexor pollicis brevis,
opponens pollicis brevis and the adductor pollicis
brevis.
■ The hypothenar muscles.
■ Palmaris brevis, abductor digiti minimi, flexor digiti
minimi brevis, and opponens digiti minimi.
■ The lumbricals.
■ The interossei.
• “Intrinsic plus” posture: results from pull of the interossei
resulting in MCP flexion and IP extension
(Fig. 19.32).
Blood supply
• The brachial artery is palpable just medial to the biceps
tendon at the level of the elbow.
Figure 19.28 The common configuration of the vincula. (From Chase RA. Atlas of
Hand Surgery. vol II. Philadelphia: WB Saunders; 1984.)
FDP tendon
Vinculum longus
profundus
FDS tendon
Mesotenon
Vinicula brevia
Vinculum brevia
Vinculum longus
superficialis
Figure 19.29 Flexor tendon zones are classified for their relevance to flexor
tendon injuries. (Redrawn after Chase RA. Atlas of Hand Surgery, vol II.
Philadelphia: WB Saunders; 1984.)
Superficialis insert
Proximal A3
Distal A2
Proximal A1
Transverse
carpal ligament
Carpal tunnel
Distal
Zones
I
II
III
IV
V
Middle
Proximal
• The A2 and A4 pulleys are most important for preventing
bowstringing in the digits.
• The longitudinal blood supply to a tendon comes from its
musculotendinous junction and its insertion site into
bone.
• The segmental blood supply derives from the
mesotenon and from the vincula within the digital
sheaths.
■ The vincula brevia form the residual mesotenon at the
sites of insertion of the profundus and superficialis
tendons on the phalanges.
■ The vincula longa are the flexible, vessel-carrying
bands to each tendon in the area where the complete
mesotenon has disappeared (Fig. 19.28).
• The flexor tendons and the associated synovial and
fibrous sheaths are divided into clinically important
zones (Fig. 19.29):
■ Zone 1: The area traversed by the flexor
digitorum profundus distal to the insertion
of the flexor digitorum superficialis on the middle
phalanx.
■ Zone 2: From the proximal end of Zone 1 to the
proximal end of the digital fibrous sheath.
■ Zone 3: From the proximal end of the finger pulley
system (Al) to the distal end of the transverse carpal
ligament.
■ Zone 4: The carpal tunnel.
■ Zone 5: From the proximal border of the transverse
carpal ligament to the musculotendinous junctions of
the flexor tendon.
• Synovial sheaths are closed sacs around the tendons
composed of a visceral layer on the tendon surface and a
parietal layer on the fibrous sheath surface.
332
•
• Essential anatomy of the upper extremity
19
Figure 19.30 Superficial and deep intrinsic muscles in the hand. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Radial artery and venae comitantes
Flexor carpi radialis tendon
Tendinous sheath of
flexor pollicis longus
(radial bursa)
Median nerve
Palmaris longus tendon and
palmar carpal ligament
Transverse carpal
ligament (flexor
retinaculum)
Thenar muscles
Proper palmar
digital nerves
of thumb
(Synovial)
tendinous
sheath of flexor
pollicis longus
(radial bursa)
Probe in 1st
lumbrical
fascial sheath
Common palmar
digital artery
Proper palmar
digital arteries
Septa from palmar
aponeurosis forming canals
Palmar aponeurosis
(reflected)
Ulnar artery with venae comitantes and ulnar nerve
Flexor carpi ulnaris tendon
Common flexor sheath (ulnar bursa) containing
superficialis and profundus flexor tendons
Pisiform
Deep palmar branch of ulnar artery and deep
branch of ulnar nerve
Superficial branch of ulnar nerve
Palmar digital nerves to 5th finger and
medial half of 4th finger
Median nerve
Common flexor sheath (ulnar bursa)
Superficial palmar arterial and venous arches
2nd, 3rd, and 4th lumbrical muscles (in fascial sheaths)
(Synovial) flexor tendon sheaths of fingers
Anterior (palmar) views
Proper palmar digital nerves of thumb
Fascia over adductor pollicis muscle
1st dorsal interosseous muscle
Probe in dorsal extension of thenar
space deep to adductor pollicis muscle
Thenar space (deep to flexor tendons
and 1st lumbrical muscle)
Septum separating thenar from midpalmar space
Common palmar digital artery
Proper palmar digital arteries and nerves
Ulnar artery
and nerve
Common palmar
digital branches
of median nerve (cut)
Hypothenar
muscles
Common flexor
sheath (ulnar
bursa)
5th finger
(synovial)
tendinous sheath
Probe in
midpalmar space
Midpalmar space
(deep to flexor
tendons and
lumbrical muscles)
Insertion of
flexor digitorum
superficialis tendon
Insertion of flexor digitorum
profundus tendon
Annular and cruciform parts of fibrous sheath
over (synovial) flexor tendon sheaths
Superficial palmar
branch of radial
artery and recurrent
branch of median
nerve to thenar
muscles
333
Blood supply
Figure 19.31 Superficial and deep intrinsic muscles in the hand. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Pronator quadratus muscle
Ulnar nerve
Ulnar artery and palmar carpal branch
Flexor carpi ulnaris tendon
Palmar carpal arterial arch
Pisiform
Median nerve
Abductor digiti minimi muscle (cut)
Deep palmar branch of ulnar artery
and deep branch of ulnar nerve
Flexor digiti minimi brevis muscle (cut)
Opponens digiti minimi muscle
Deep palmar (arterial) arch
Palmar metacarpal arteries
Common palmar digital arteries
Deep transverse metacarpal ligaments
Radial artery and palmar carpal branch
Radius
Superficial palmar branch of radial artery
Flexor retinaculum (transverse
carpal ligament) (reflected )
Opponens pollicis muscle
Branches of median nerve
to thenar muscles and to 1st
and 2nd lumbrical muscles
Abductor pollicis
brevis muscle (cut )
Flexor pollicis
brevis muscle
Adductor pollicis
muscle
1st dorsal
interosseous muscle
Branches from deep
branch of ulnar nerve
to 3rd and 4th lumbrical
muscles and to all
interosseous muscles
Lumbrical muscles (reflected )
Anterior (palmar) view
Radius
Ulna
Palmar interosseous
muscles (unipennate)
Deep transverse
metacarpal ligaments
Radius
Ulna
Abductor digiti
minimi muscle
Radial artery
Abductor pollicis
brevis muscle
Dorsal interosseous
muscles (bipennate)
Anterior
(palmar) view
Tendinous slips
to extensor
expansions
(hoods)
Note: Arrows indicate action of muscles.
Posterior
(dorsal) view
1
2
3
1
2
3
4
334
•
• Essential anatomy of the upper extremity
19
■ In the hand: travels deep to the palmaris brevis and
the hypothenar fascia where it divides into a deep
palmar branch (contributes to deep palmar arch) and a
superficial palmar branch (dominant contributor to the
superficial palmar arch) (Fig. 19.34).
■ The superficial palmar arch gives rise to three common
digital arteries and multiple branches to intrinsic
muscles and skin.
■ The deep palmar arch is the major source of blood
supply to the thumb and to the radial side of the index
finger.
■ The first metacarpal artery is the prime source of blood
supply to the radial and ulnar proper digital arteries of
the thumb and the radial proper digital artery of the
index finger.
■ After giving its branch to the index finger, the first
metacarpal artery becomes the princeps pollicis (the
primary source of blood supply to the thumb).
■ A dorsal carpal arch is formed from dorsal arteries
(originate proximally from the posterior interosseous
artery and a dorsal perforating branch of the anterior
interosseious artery), and from branches of the radial
and ulnar arteries.
■ Dorsal metacarpal arteries originate from this arch and
extend distally to the margins of the fingers. These
arteries are joined by branches from the radial and
ulnar arteries to form a dorsal carpal arch.
Peripheral nerves
• General peripheral nerve anatomy:
■ The epineurium is the tubular fibrous support
structure surrounding the entire nerve; it also courses
between the fascicles to create an internal topography.
■ Each fascicle is covered by perineurium.
■ Within each fascicle are separate axons, some
myelinated and some unmyelinated. Motor, sensory,
and sympathetic fibers are present within each
peripheral nerve.
■ Blood vessels are found on the epineurial surface and
in the internal supporting structure of the nerve.
• The flexor pollicis longus divides the hand into a median
and ulnar-innervated portion from the motor standpoint.
The ulnar nerve is far less important from the standpoint
of hand sensation but is very important for its motor
innervation of all the hypothenar muscles and interossei.
• When there is paralysis of any of the three major motor
nerves, thumb stability is compromised.
■ Median nerve palsy results in lost opposition.
■ Ulnar nerve palsy results in adduction weakness.
■ Radial nerve palsy destroys extension and dorsal
abduction function.
Radial nerve
• Arises from the posterior cord of the brachial plexus
(C6–8) (Fig. 19.35).
• Divides into terminal deep and superficial branches at
the proximal forearm (Fig. 19.36).
• Branches into the radial and ulnar arteries at the bicipital
aponeurosis of the elbow (Fig. 19.33).
• Supplementary arteries in the forearm include the
anterior interosseous artery, the posterior interosseous
artery, and the median artery.
• The radial artery continues distally between the
brachioradialis and FCR muscles.
■ At the wrist: located near the styloid process of the
radius, travels dorsally, crossing the “anatomic snuffbox”
deep to the tendons of the APL, EPB, and EPL.
■ In the hand: penetrates between the first and second
metacarpal bones, through an arcade in the first dorsal
interosseous muscle, to enter the palm and form the
deep palmar arch.
■ A superficial branch of the radial artery arises at the
level of the distal radius and courses over or through
the APB to contribute to the superficial palmar arch.
• The ulnar artery gives off the common interosseous
artery soon after its takeoff, which itself branches into the
anterior and posterior interosseous arteries.
■ The ulnar artery continues distally under the FCU
muscle.
■ At the wrist: it lies radial to the pisiform and ulnar to
the hook of the hamate and travels into the hand
through Guyon’s canal.
Figure 19.32 All interossei act as prime flexors of the metacarpophalangeal joints
since they pass palmar to the joint axis. Extensions into the lateral bands result in
extension of the interphalangeal joints. (From Chase RA. Atlas of Hand Surgery,
vol 1. Philadelphia: WB Saunders; 1973.)
(cont’d)
335
Peripheral nerves
Figure 19.33 Upper arm vascular anatomy and surrounding structures. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Anterior view
Deltoid muscle
Coracobrachialis muscle
Short head (cut )
Long head (cut )
Musculocutaneous nerve
Brachialis muscle
Biceps brachii muscle (cut ) and tendon
Lateral antebrachial cutaneous nerve
(from musculocutaneous nerve)
Deep branch
Superficial branch
Supinator muscle
Brachioradialis muscle
Radial artery
Pronator teres muscle (partially cut )
Median nerve
Flexor pollicis longus muscle
Flexor carpi radialis
tendon (cut )
Flexor retinaculum
(transverse carpal
ligament)
Superficial branch
of radial nerve
Recurrent (motor)
branch of
median nerve to
thenar muscles
Common palmar
digital branches
of median nerve
Proper palmar
digitial branches
of median nerve
Intercostobrachial nerve
Medial brachial
cutaneous nerve
Radial nerve
Ulnar nerve
Medial antebrachial
cutaneous nerve
Median nerve
Brachial artery
Bicipital aponeurosis
Humeral head (cut)
Ulnar head
Pronator teres muscle
Flexor carpi radialis muscle (cut)
Humeroulnar head
Radial head
Flexor digitorum
superficialis muscle (cut)
Flexor digitorum profundus muscle
Flexor carpi ulnaris muscle
Ulnar artery and nerve
Dorsal branch of ulnar nerve
Flexor digitorum superficialis tendons (cut)
Deep palmar branch of ulnar artery and deep branch of ulnar nerve
Superficial branch of ulnar nerve
Superficial palmar arch (cut)
Common palmar digital branch of ulnar nerve
Communicating branch of median nerve with ulnar nerve
Proper palmar digital branches of ulnar nerve
Biceps brachii muscle
Radial nerve
336
•
• Essential anatomy of the upper extremity
19
Figure 19.34 Hand vascular anatomy and surrounding structures. (Reprinted with permission from © Elsevier Inc. All Rights Reserved.)
Radial artery
Median nerve and palmar branch
Superficial palmar branch of radial artery
Abductor pollicis brevis muscle (cut )
Opponens pollicis muscle
Flexor pollicis brevis muscle
Recurrent (motor) branch of
median nerve to thenar muscles
Proper digital nerves
and arteries to thumb
Adductor pollicis muscle
Branches of median nerve to
1st and 2nd lumbrical muscles
Flexor tendons, synovial
and fibrous sheaths
Ulnar artery and nerve
Palmar carpal ligament (continuous
with extensor retinaculum)
Flexor retinaculum (transverse
carpal ligament)
Deep palmar branch of ulnar artery
and deep branch of ulnar nerve
Superficial branch of ulnar nerve
Common flexor sheath
(ulnar bursa)
Superficial palmar (arterial) arch
Common palmar digital nerves
and arteries
Communicating branch of
median nerve with ulnar nerve
Proper palmar digital nerves
and arteries
Branches of proper palmar
digital nerves and
arteries to dorsum of
middle and distal
phalanges
Radial artery
Median nerve
Superficial palmar branch of radial artery
Deep palmar (arterial) arch and
deep branch of ulnar nerve
Princeps pollicis artery
Proper digital arteries
and nerves of thumb
Distal limit of
superficial palmar arch
Radialis indicis artery
Palmar metacarpal arteries
Common palmar digital arteries
Proper palmar digital arteries
Proper palmar digital nerves from median nerve
Ulnar artery and nerve
Palmar carpal branches of
radial and ulnar arteries
Pisiform
Deep palmar branch of
ulnar artery and deep
branch of ulnar nerve
Branches to hypothenar
muscles
Superficial branch of
ulnar nerve
Hook of hamate
Communicating branch
of median nerve with
ulnar nerve
Proper palmar digital
nerves from ulnar nerve
Deep palmar branch of
ulnar nerve to 3rd and
4th lumbrical, all
interosseous, adductor
pollicis, and deep head
of flexor pollicis brevis
muscles
337
Peripheral nerves
Figure 19.35 The proximal radial nerve wraps posteriorly around the humerus and then proceeds in a dorsal-radial direction distally. (Reprinted with permission from
© Elsevier Inc. All Rights Reserved.)
Posterior view
Suprascapular nerve (C5, 6)
Dorsal scapular nerve (C5)
Supraspinatus muscle
Levator scapulae
muscle (supplied
also by branches
from C3 and C4)
Rhomboid
minor muscle
Rhomboid
major muscle
Infraspinatus muscle
Teres major muscle
Lower subscapular nerve (C5, 6)
Posterior brachial cutaneous nerve
(branch of radial nerve in axilla)
Triceps brachii muscle
Long head
Lateral head
Medial head
Triceps brachii tendon
Medial epicondyle
Olecranon
Anconeus muscle
Extensor digitorum muscle
Extensor carpi ulnaris muscle
Extensor carpi
radialis brevis
muscle
Extensor carpi radialis
longus muscle
Brachioradialis muscle
Brachialis muscle (lateral
part; remainder of muscle
supplied by musculo-
cutaneous nerve)
Lateral intermuscular
septum
Posterior antebrachial
cutaneous nerve
Inferior lateral brachial
cutaneous nerve
Deltoid muscle
Teres minor muscle
Axillary nerve (C5, 6)
Superior lateral brachial
cutaneous nerve
Radial nerve
(C5, 6, 7 , 8, T1)
Inconstant contribution