(A)

(B)

Figure 1.2: Illustrating the A- tip pinch grip and B- lateral (key) pinch.

Acknowledgement: www.sagepub.com

Figure 1.3: Muscles that help with the movement of the thumb.

Acknowledgement: Drake RL, Vogl W and Mitchell AWM. Grey’s anatomy for students, 2nd

Edition, London UK; Elseveir Churchill Livingstone publication; 2007b: 721

Figure 1.4: Extrinsic muscles of the hand and thumb. (A) showing the superficial layer (B) showing the

intermediate layer while (C) shows the deep layers of flexor muscles.

Acknowledgement: Drake RL, Vogl W and Mitchell AWM. Grey’s anatomy for students, 2nd

Edition, London UK; Elseveir Churchill Livingstone publication; 2007c: 700-702

A B C

Figure 1.7: Illustrating the normal histology of the flexor tendon of the fingers (magnification x20) wherein Ent-

endotendineum, Ept- epitendineum, Tf- collection of collagen in extra cellular matrix and TC-

tendinocyte nuclei.

Acknowledgement: Ross MH and Pawlina W. Histology- A text book and atlas, 5th Edition

Lippincott Williams and Wilkins publication; 2006: 179

TC

µ20

Figure 1.8: Illustrating the normal histology of the flexor tenosynovium (magnification x20) wherein T- flexor

tendon, E- epitendineum, S- thin outer fibrous tendon sheath, TSS- tendon sheath space. The

magnification is x20.

Acknowledgement: Steven A and Lowe J. Human Histology, 3rd Edition, Elseveir Mosby

publication; 2005: 250

µ20

A

B

Figure 1.9: Skeleton of the hand (A), while (B) shows the carpal arch.

Acknowledgement: Drake RL, Vogl W and Mitchell AWM. Grey’s anatomy for

students, London UK; 2nd Edition, Elseveir Churchill Livingstone publication;

2007a: 709

Figure 1.10: Cross section of the carpal tunnel.

Acknowledgement: Wheat J, Satherley L, Stephens S and Enoch S. Applied Surgical Anatomy for

MRCS OSCE, Doctors Academy Publication, 1st Edition, Cardiff, UK, 2009:17

Flexor Pollicis Longus Tendon

Flexor Carpi Radialis Tendon

Radial Artery

Palmaris Longus Tendon

Flexor Retinaculum

Median Nerve

Cephalic Vein

Extensor Pollicis Longus Tendon

Extensor Carpi Radialis Longus

Tendon

Abductor Pollicis Longus

Extensor Pollicis Brevis Tendon

Flexor Digitorum Profundus Tendons

Flexor Digitorum SuperficialisTendons

Figure 1.11 : Showing the different covering of a peripheral nerve.

Acknowledgement: www.sosondoc.egloos.com

Figure 1.15A: Accessory head of Flexor Pollicis Longus (Arrowed).

1cm 2cm

B

A

Figure 1.15B: Interconnection ( ) between the Flexor Digitorum Profundus of ring

finger (A) and little fingers (B).

1cm 2cm

A B

Figure 1.15C: Interconnection ( ) between the Flexor Digitorum Profundus of index finger

(A) and Flexor Pollicis Longus (B).

1cm 2cm

Figure 2.1: Morphological types of muscle based on their general form and fascicular architecture.

Acknowledgement: Stradring S, Grays anatomy, The anatomical basis of clinical practice,

39th Edition, London UK, by Elseveir Churchill Livingstone publication; 2005: 113

Figure 2.2: Shows the relations of FPL, FDS, FDP, FCU and FCR.

FPL tendon

FCR tendon

FCU tendon

FDP (index) tendon

FDS (middle) tendon

Flexor retinaculum

Median nerve

FDS tendon

Distal end of the muscle

Proximal end of the muscle

Intramuscular part of tendon

Distal end of the tendon

Carpal tunnel

Tendon length

Figure 2.4: Shows the method used to calculate the tendon length.

Distal end of the muscle

Proximal end of the muscle

Intramuscular part of tendon

Level of carpal tunnel

Tendon length

Ten

do

n len

gth

1

Figure 2.5: Illustrating the method used to calculate the tendon length of multipennate

muscle (FDS). The mean of all the extra muscular tendon length up to the

carpal tunnel were taken.

Midpoint of the muscle

(midpoint between the origin and distal

Insertion of the muscle)

Lateral Medial

10º 12º 11º 15º

Lateral

angle

Medial

angle

10º 12º

11º 15º

9º 12º

Mean 10º 13º

Angle of

pennation 13º

Figure 2.6: Illustrating the method undertaken to calculate the midpoint and angle of pennation in a

multipennate muscle.

9º 12º

FDS to little finger

Origin of the FDS muscle belly

Intramuscular part of tendon (intact)

Distal end of the muscle

FDS to ring finger

FDS to middle finger

FDS to index finger

Figure 2.8: Illustrating the FDS muscle after being removed from the cadaver for measuring the

mass and density. Note that the intramuscular part of the tendon had been left intact.

Figure 2.11: Demonstrating the different angles of flexion of the right thumb, index and middle

fingers in mid prone position. (A) at rest, (B): initial movement, (C): mid position and (D)

fully flexed.

(C)

58°

30°

(D)

85°

70°

(A)

52°

(B)

Figure 2.12: Demonstrating the different angles of flexion of the right thumb, index and middle fingers in

supination position. (A) at rest, (B): initial movement, (C): mid position and (D) fully flexed.

30°

12 °

7°

(B) (A)

(C)

82 °

43 °

35 °

69 °

85 °

70 °

62 °

(D)

FCR tendon removed 2cms above its

bony insertion

FCU tendon removed 2cms above its bony insertion

FDP (index) tendon removed 2cms

above the carpal tunnel

FPL tendon removed 2cms above the carpal tunnel FDS (index) tendon removed 2cms

above the carpal tunnel

Figure 2.13: Shows the five tendons that were used to calculate TCSA using the Image Pro-Plus software.

Median nerve

Measuring tape

Figure 2.14: Shows the median nerve samples that were used to calculate the cross sectional area using the

Image Pro-Plus software.

Median nerve before the carpal tunnel Median nerve at the carpal tunnel

Median nerve after the carpal tunnel

200 medical students

(Mean age 18 (females) and 21 years (males)

Number of students who played

musical instruments as amateurs

(from 0-grade 8)

= 171 (103 =females and

68=males)

Number of students non

musicians

= 29 (18 =females and

11=males)

Number of students with tendinous

interconnection

= 10 (=5%)

Number of students with

tendinous interconnection

= 2 (=7%)

Females =8

Males =2

Females: male=1:4 Females =2

Overall percentage of interconnection =6%

Table 3.1: Shows the general statistics of volunteer study.

Right hand interconnection: 8 volunteers

Left hand interconnection =7 volunteers

Bilateral = 3 volunteers

Figure 3.25: Illustrating the tenosynovial interconnection (Conn) between the FPL and FDP (Index) in

the left hand of Volunteer ‘2’.

1 cm

1 c

m

Interconnection- 0.5 cms

Thickness of interconnection- 0.2 cms

0.5 cm

1St metacarpal

Middle

phalanx of index

Proximal Distal

Lumbricals

Thenar muscles

Lateral

Medial

FPL FDP (index)

FPS (index)

Figure 3.26: Illustrating the tenosynovial interconnection (Prob Conn) between the FPL and FDP (Index

finger) in the left hand of Volunteer ‘3’.

1 cm

1 c

m

0.5 cm

Interconnection- 0.8 cms

Thickness of interconnection- 0.2 cms

Thenar muscles

FPL

FDP (index)

FDS (index)

Lumbricals

Hypothenar muscles

Lateral

Medial

Proximal Distal

FPL C

FDP

(I)

Figure 3.27 : Illustrating the probable tendinous interconnection (C) between the FPL and FDP (Index

finger) in the right hand of Volunteer ‘9’. This was not very conclusive.

1 cm

1 c

m

Length of Interconnection- 0.7 cms

Thickness of interconnection- 0.2 cms

0.5 cm

Thenar muscles

Hyopthenar muscles

FDS (index)

FDP (index)

FPL

Lumbricals

Lateral

Medial

Proximal

Distal

C

Figure 3.28: Illustrating the tendinous interconnection (C) between the FPL and FDP (Index finger) in the

left hand of Volunteer ‘12’.

Interconnection- 0.5 cms

Thickness of interconnection- 0.1 cms

1 cm

1 c

m

0.5 cm

Medial

Lateral

Proximal Distal

FDS (ring)

Lumbricals

FDP (index)

FPL

1 cm

1 c

m

Interconnection- 0.2 cms

Thickness of interconnection- 0.2 cms

0.5 cm

1St metacarpal

Middle

phalanx of index

Proximal Distal

Lumbricals

Thenar muscles

Lateral

Medial

FPL

FDP (index)

FPS (index)

Figure 3.44: Illustrating the tendinous interconnection (C) between the FPL and FDP (Index finger) in the

left hand of Volunteer ‘1’. Taken during repeatability and reliability study.

C