FLEXOR AND EXTENSOR FLEXOR AND EXTENSOR RETINACULA OF RETINACULA OF UPPER LIMBUPPER LIMB

A SEMINAR BY V.JANARTHANAN

I-MBBS

FLEXOR RETINACULUM OF FLEXOR RETINACULUM OF UPPER LIMB UPPER LIMB• INTRODUCTION: INTRODUCTION: Thickening of Thickening of distaldistal antebrachialantebrachial fascia fascia

justjust proximalproximal to to radiocarpalradiocarpal ( (wristwrist) ) jointjoint. . ContinuousContinuous with with extensor extensor retinaculumretinaculum at at marginsmargins of of forearmforearm. This . This structurestructure is distinct from the is distinct from the transverse carpal ligamenttransverse carpal ligament, commonly called "the , commonly called "the flexor flexor retinaculumretinaculum," which forms the ," which forms the roofroof of the of the carpal tunnelcarpal tunnel. .

Synonym:Synonym: flexor flexor retinaculumretinaculum of forearm of forearm, , palmarpalmar

carpal ligament carpal ligament, , antebrachial flexor retinaculum,antebrachial flexor retinaculum, retinaculum musculorum flexorum manus, retinaculum musculorum flexorum manus, ligamentum carpi transversumligamentum carpi transversum . .

LOCATION(SURFACE MARKING):LOCATION(SURFACE MARKING):

• PROXIMAL MEDIAL BORDER: PISIFORM BONEPROXIMAL MEDIAL BORDER: PISIFORM BONE

• PROXIMAL LATERAL BORDER: TUBERCLE OF SCAPHOIDPROXIMAL LATERAL BORDER: TUBERCLE OF SCAPHOID

• DISTAL MEDIAL BORDER: HOOK OF HAMATEDISTAL MEDIAL BORDER: HOOK OF HAMATE

• DISTAL LATERAL BORDER: CREST OF TRAPEZIUMDISTAL LATERAL BORDER: CREST OF TRAPEZIUM

• #CONCAVE PROXIMALLY & DISTALLY##CONCAVE PROXIMALLY & DISTALLY#

MEASUREMENT:MEASUREMENT:

• AVERAGE: 2 X 2 CM.AVERAGE: 2 X 2 CM.

• MAY VARY DEPENDING ON THE SIZE OF MAY VARY DEPENDING ON THE SIZE OF THE WRISTTHE WRIST

1.median nerve 2.tendons of flexor

digitorum superficialis

3.tendons of flexor digitorum profundus

4.tendon of flexor pollicis longus

5.tendon of flexor carpi radialis

ATTACHMENT:ATTACHMENT:

• SUPERO-MEDIAL: PISIFORM BONESUPERO-MEDIAL: PISIFORM BONE

• SUPERO-LATERAL: TUBERCLE OF SCAPHOIDSUPERO-LATERAL: TUBERCLE OF SCAPHOID

• INFERO-MEDIAL: HOOK OF HAMATEINFERO-MEDIAL: HOOK OF HAMATE

• INFERO-LATERAL: EITHER SIDE OF ANTERIOR INFERO-LATERAL: EITHER SIDE OF ANTERIOR GROOVE GROOVE

OF TRAPEZIUM*OF TRAPEZIUM*

*THIS FORMS A SEPARATE TUNNEL FOR THE *THIS FORMS A SEPARATE TUNNEL FOR THE TENDON OF FLEXOR CARPI RADIALIS TENDON OF FLEXOR CARPI RADIALIS

Flexor retinaculum (FR) 1 scaphoid 2 trapezium 3 pisiform 4 hamate

4 hamate

RELATIONS(SUPERFICIAL):RELATIONS(SUPERFICIAL):

• TENDON OF PALMARIS LONGUSTENDON OF PALMARIS LONGUS• PALMAR CUTANEOUS BRANCH OF MEDIAN NERVEPALMAR CUTANEOUS BRANCH OF MEDIAN NERVE• PALMAR CUTANEOUS BRANCH OF ULNAR NERVEPALMAR CUTANEOUS BRANCH OF ULNAR NERVE• ULNAR VESSELSULNAR VESSELS• ULNAR NERVEULNAR NERVE• FLEXOR CARPI ULNARIS HAS PARTIAL INSERTIONFLEXOR CARPI ULNARIS HAS PARTIAL INSERTION• THENAR AND HYPOTHENAR MUSCLES HAVE THENAR AND HYPOTHENAR MUSCLES HAVE

PARTIAL ORIGINPARTIAL ORIGIN

• MEASUREMENT:MEASUREMENT:

RELATIONS(DEEP):RELATIONS(DEEP):

• MEDIAN NERVEMEDIAN NERVE

• TENDONS OF FLEXOR DIGITORUM TENDONS OF FLEXOR DIGITORUM SUPERFICIALISSUPERFICIALIS

• TENDONS OF FLEXOR DIGITORUM TENDONS OF FLEXOR DIGITORUM PROFUNDUSPROFUNDUS

• TENDONS OF FLEXOR POLLICIS LONGUSTENDONS OF FLEXOR POLLICIS LONGUS

• ULNAR BURSAULNAR BURSA

• RADIAL BURSARADIAL BURSA

• TENDON OF FLEXOR CARPI RADIALISTENDON OF FLEXOR CARPI RADIALIS

PURPOSE:PURPOSE:

• HOLDS THE FLEXOR TENDONS IN HOLDS THE FLEXOR TENDONS IN PLACEPLACE

• ACTS AS A PULLEY DUE TO THE ACTS AS A PULLEY DUE TO THE PRESENCE OF SYNOVIAL SHEATHSPRESENCE OF SYNOVIAL SHEATHS

• MAINTAINS THE ANTERIOR MAINTAINS THE ANTERIOR CONCAVITY OF THE PALMCONCAVITY OF THE PALM

CLINICAL ANATOMY:CLINICAL ANATOMY:

• CARPAL TUNNEL SYNDROME• Carpal tunnel syndrome is a common disorder that causes pain, and

interferes with the use of the hand. It is caused by pressure on the median nerve as the nerve passes through a canal formed by the bones and ligaments in the wrist (the carpal tunnel). A wide variety of conditions can cause the carpal tunnel to narrow and put pressure on the median nerve, including injuries, such as wrist fractures; arthritis complicated by swelling of the tendons in the carpal tunnel; pregnancy, which may cause the synovium around the tendons to thicken; and glandular abnormalities, such as diabetes and thyroid disorders. Work that involves repetitive wrist motions may also cause carpal tunnel syndrome. Symptoms of carpal tunnel syndrome include pain and numbness in the thumb and in the index, middle, and ring fingers. Many people wake at night with these symptoms. Some sufferers experience weakness of hand muscles and may drop objects. Symptoms often occur when the wrist is flexed during such activities as driving a car or holding a book while reading.Doctors treat carpal tunnel syndrome by attempting to improve the underlying condition. In many cases, doctors apply a splint to the wrist and prescribe anti-inflammatory medications. In some cases, surgery is performed to relieve symptoms and to prevent permanent damage to the median nerve

REVIEW:REVIEW:

• The The flexor retinaculumflexor retinaculum ( (transverse carpal ligamenttransverse carpal ligament, or , or anterior anterior annular ligamentannular ligament) is a strong, fibrous band, which arches over the ) is a strong, fibrous band, which arches over the carpuscarpus, converting the deep groove on the front of the , converting the deep groove on the front of the carpal bonescarpal bones into a tunnel, the into a tunnel, the carpal tunnelcarpal tunnel, through which the Flexor tendons of , through which the Flexor tendons of the digits and the the digits and the median nervemedian nerve pass. pass.

• It is attached, medially, to the It is attached, medially, to the pisiformpisiform and the and the hamulus of the hamate bonehamulus of the hamate bone; laterally, to the tubercle of the ; laterally, to the tubercle of the scaphoidscaphoid, and to the medial part of the volar surface and the ridge of , and to the medial part of the volar surface and the ridge of the the trapeziumtrapezium..

• It is continuous, above, with the It is continuous, above, with the volar carpal ligamentvolar carpal ligament; and below, ; and below, with the with the palmar aponeurosispalmar aponeurosis. It is crossed by the ulnar vessels and . It is crossed by the ulnar vessels and nerve, and the cutaneous branches of the median and nerve, and the cutaneous branches of the median and ulnar nervesulnar nerves..

• At its lateral end is the tendon of the At its lateral end is the tendon of the Flexor carpi radialisFlexor carpi radialis, which lies , which lies in the groove on the greater multangular between the attachments of in the groove on the greater multangular between the attachments of the ligament to the bone.the ligament to the bone.

• On its volar surface the tendons of the On its volar surface the tendons of the Palmaris longusPalmaris longus and and Flexor carpi ulnarisFlexor carpi ulnaris are partly inserted; below, it gives origin to the are partly inserted; below, it gives origin to the short muscles of the short muscles of the thumbthumb and and little fingerlittle finger..

EXTENSOR RETINACULUM OFEXTENSOR RETINACULUM OF UPPER LIMB UPPER LIMB

• INTRODUCTION:

• A strong fibrous band formed as a thickening of the antebrachial deep fascia, stretching obliquely across the back of the wrist, attaching deeply to ridges on the dorsal aspect of the radius, triquetral and pisiform bones, binding down the extensor tendons of the fingers and thumb.

• Synonym: retinaculum extensorum, dorsal carpal ligament, ligamentum carpi dorsale, retinaculum musculorum extensorum manus .

LOCATION:LOCATION:

• The extensor retinaculum (dorsal carpal ligament) is an anatomical term for the thickened part of the antebrachial fascia that holds the tendons of the extensor muscles in place. It is located on the back of the forearm, just proximal to the hand. It is continuous with the palmar carpal ligament, which is located on the anterior side of the forearm.

• It is a strong, fibrous band, extending obliquely downward and medialward across the back of the wrist, and consisting of part of the deep fascia of the back of the forearm, strengthened by the addition of some transverse fibers.

• It is attached, medially, to the styloid process of the ulna and to the triangular and pisiform bones; laterally, to the lateral margin of the radius; and, in its passage across the wrist, to the ridges on the dorsal surface of the radius.

MEASUREMENT:MEASUREMENT:

• 2-3 CM. THICK

• LENGTH VARIES GREATLY DEPENDINGON VARIOUS FACTORS

ATTACHMENTS:ATTACHMENTS:

• LATERAL : LOWER SALIENT PART OF THE• ANTERIOR BORDER OF RADIUS• INTERMEDIATE: LONGITUDINAL RIDGES • ON THE POSTERIOR • SURFACE OF THE• LOWER END OF RADIUS AND • HEAD OF ULNA• MEDIAL: i) STYLOID PROCESS OF ULNA• ii) MEDIAL SIDE OF CARPUS• (PISIFORM & TRIQUETRAL)

RELATIONS(COMPARTMENTS):RELATIONS(COMPARTMENTS):

COMPARTMENT STRUCTURES

I i) ABDUCTOR POLLICIS LONGUS

ii) EXTENSOR POLLICIS BREVIS

II i) EXTENSOR CARPI RADIALIS LONGUS

ii) EXTENSOR CARPI RADIALIS BREVIS

III i) EXTENSOR POLLICIS LONGUS

IV i) EXTENSOR DIGITORUM

ii) EXTENSOR INDICES

iii) POSTERIOR INTEROSSEOUS NERVE

iv) ANTERIOR INTEROSSEOUS ARTERY

V i) EXTENSOR DIGITI MINIMI

VI i) EXTENSOR CARPI ULNARIS

PURPOSE:PURPOSE:

• HOLDS THE EXTENSOR TENDONS IN PLACE

• ACTS AS A PULLEY DUE TO THE PRESENCE OF SYNOVIAL SHEATHS

CLINICAL ANATOMY:CLINICAL ANATOMY:

• Extensor Retinaculum Graft for Chronic Boxer’s Knuckle

REVIEW:REVIEW:

• The extensor retinaculum (dorsal carpal ligament) is an anatomical term for the thickened part of the antebrachial fascia that holds the tendons of the extensor muscles in place. It is located on the back of the forearm, just proximal to the hand. It is continuous with the palmar carpal ligament, which is located on the anterior side of the forearm.

• It is a strong, fibrous band, extending obliquely downward and medialward across the back of the wrist, and consisting of part of the deep fascia of the back of the forearm, strengthened by the addition of some transverse fibers.

• It is attached, medially, to the styloid process of the ulna and to the triangular and pisiform bones; laterally, to the lateral margin of the radius; and, in its passage across the wrist, to the ridges on the dorsal surface of the radius.

COURTESY:COURTESY: BOOKS:BOOKS: CUNNINGHAM’SCUNNINGHAM’S B.D.CHAURASIA’SB.D.CHAURASIA’S GRAY’SGRAY’S WEBSITES:WEBSITES: www.thefreedictionary.com/www.thefreedictionary.com/retinaculumretinaculum - 27k - 27k en.wikipedia.org/wiki/en.wikipedia.org/wiki/RetinaculumRetinaculum - 14k – - 14k – mywebpages.comcast.net/wnor/lesson5flexretinac&palmapon.htm - 4k –mywebpages.comcast.net/wnor/lesson5flexretinac&palmapon.htm - 4k – cancerweb.ncl.ac.uk/cgi-bin/omd?extensor+cancerweb.ncl.ac.uk/cgi-bin/omd?extensor+retinaculumretinaculum - 4k – - 4k – www.britannica.com/eb/topic-665283/www.britannica.com/eb/topic-665283/retinaculumretinaculum - 26k - - 26k - www.netterimages.com/image/www.netterimages.com/image/retinaculumretinaculum.htm - 69k -.htm - 69k - www.encyclopedia.com/doc/1O8-www.encyclopedia.com/doc/1O8-retinaculumretinaculum.html - 62k -.html - 62k - findarticles.com/p/articles/mi_qa3767/is_200201/ai_n9062792 - 30k –findarticles.com/p/articles/mi_qa3767/is_200201/ai_n9062792 - 30k – medical-dictionary.thefreedictionary.com/medical-dictionary.thefreedictionary.com/retinaculumretinaculum - 30k – - 30k – www.ingentaconnect.com/content/els/12973203/2003/00000022/00000002/art00029 -www.ingentaconnect.com/content/els/12973203/2003/00000022/00000002/art00029 - classes.kumc.edu/sah/resources/handkines/ligaments/wdsextreti.htm - 4k –classes.kumc.edu/sah/resources/handkines/ligaments/wdsextreti.htm - 4k – classes.kumc.edu/sah/resources/handkines/ligaments/wvstflexret.htm - 4k –classes.kumc.edu/sah/resources/handkines/ligaments/wvstflexret.htm - 4k – linkinghub.elsevier.com/retrieve/pii/S0363502306003820 –linkinghub.elsevier.com/retrieve/pii/S0363502306003820 – ajs.sagepub.com/cgi/content/abstract/0363546507305803v1 –ajs.sagepub.com/cgi/content/abstract/0363546507305803v1 – ajs.sagepub.com/cgi/content/full/29/5/656 –ajs.sagepub.com/cgi/content/full/29/5/656 – linkinghub.elsevier.com/retrieve/pii/S0968016003001674 –linkinghub.elsevier.com/retrieve/pii/S0968016003001674 – www.eatonhand.com/fas/fas056.htm - 3k -www.eatonhand.com/fas/fas056.htm - 3k - www.netterimages.com/image/extensor-www.netterimages.com/image/extensor-retinaculumretinaculum.htm - 28k -.htm - 28k - www.instantanatomy.net/leg/areas/lowerleg/pwww.instantanatomy.net/leg/areas/lowerleg/pretinaculumretinaculum.html - 4k -.html - 4k - cat.inist.fr/?aModele=afficheN&cpsidt=2219764 –cat.inist.fr/?aModele=afficheN&cpsidt=2219764 – www.eatonhand.com/img/img00085.htm - 23k -www.eatonhand.com/img/img00085.htm - 23k - jeb.biologists.org/cgi/reprint/201/3/309.pdf –jeb.biologists.org/cgi/reprint/201/3/309.pdf – dict.die.net/dict.die.net/retinaculumretinaculum/ - 4k -/ - 4k -