Clinical Anatomy of the Hand | Reumatología Clínica

array:23 ["pii" => "S1699258X12002422" "issn" => "1699258X" "doi" => "10.1016/j.reuma.2012.10.004" "estado" => "S300" "fechaPublicacion" => "2012-12-01" "aid" => "497" "copyright" => "Elsevier España, S.L.. All rights reserved" "copyrightAnyo" => "2012" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Reumatol Clin. 2012;8 Supl 2:25-32" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 26252 "formatos" => array:3 [ "EPUB" => 156 "HTML" => 21729 "PDF" => 4367 ] ] "itemSiguiente" => array:18 [ "pii" => "S1699258X12002446" "issn" => "1699258X" "doi" => "10.1016/j.reuma.2012.10.006" "estado" => "S300" "fechaPublicacion" => "2012-12-01" "aid" => "499" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Reumatol Clin. 2012;8 Supl 2:33-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 16235 "formatos" => array:3 [ "EPUB" => 172 "HTML" => 12807 "PDF" => 3256 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Clinical Anatomy of the Pelvis and Hip" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "33" "paginaFinal" => "38" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anatomía clínica de la pelvis y la cadera" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0040" "etiqueta" => "Fig. 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1313 "Ancho" => 1000 "Tamanyo" => 116736 ] ] "descripcion" => array:1 [ "en" => "In this patient (Patient 5) the angio-TAC showed complete occlusion of the right iliac artery." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Eduardo Navarro-Zarza, Pablo Villaseñor-Ovies, Angélica Vargas, Juan J. Canoso, Karla Chiapas-Gasca, Cristina Hernández-Díaz, Miguel Ángel Saavedra, Robert A. Kalish" "autores" => array:8 [ 0 => array:2 [ "nombre" => "José Eduardo" "apellidos" => "Navarro-Zarza" ] 1 => array:2 [ "nombre" => "Pablo" "apellidos" => "Villaseñor-Ovies" ] 2 => array:2 [ "nombre" => "Angélica" "apellidos" => "Vargas" ] 3 => array:2 [ "nombre" => "Juan J." "apellidos" => "Canoso" ] 4 => array:2 [ "nombre" => "Karla" "apellidos" => "Chiapas-Gasca" ] 5 => array:2 [ "nombre" => "Cristina" "apellidos" => "Hernández-Díaz" ] 6 => array:2 [ "nombre" => "Miguel Ángel" "apellidos" => "Saavedra" ] 7 => array:2 [ "nombre" => "Robert A." "apellidos" => "Kalish" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12002446?idApp=UINPBA00004M" "url" => "/1699258X/00000008000000S2/v1_201305061530/S1699258X12002446/v1_201305061530/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S1699258X12002471" "issn" => "1699258X" "doi" => "10.1016/j.reuma.2012.10.009" "estado" => "S300" "fechaPublicacion" => "2012-12-01" "aid" => "502" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Reumatol Clin. 2012;8 Supl 2:13-24" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 29983 "formatos" => array:3 [ "EPUB" => 170 "HTML" => 25708 "PDF" => 4105 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Clinical Anatomy of the Elbow and Shoulder" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "13" "paginaFinal" => "24" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anatomía clínica del hombro y el codo" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0040" "etiqueta" => "Fig. 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "From Gray's Anatomy 1918 Ed., Lea and Febiger, Philadelphia, in public domain." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1649 "Ancho" => 1490 "Tamanyo" => 249998 ] ] "descripcion" => array:1 [ "en" => "Lateral view of the scapular components of the glenohumeral joint. The labrum glenoidale (glenoid ligament) in continuity with the tendon of the long head of biceps is shown. The acromion, the coracoacromial ligament and the coracoid process form the coracacromial arch that protects superiorly the glenohumeral joint." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pablo Villaseñor-Ovies, Angélica Vargas, Karla Chiapas-Gasca, Juan J. Canoso, Cristina Hernández-Díaz, Miguel Ángel Saavedra, José Eduardo Navarro-Zarza, Robert A. Kalish" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Pablo" "apellidos" => "Villaseñor-Ovies" ] 1 => array:2 [ "nombre" => "Angélica" "apellidos" => "Vargas" ] 2 => array:2 [ "nombre" => "Karla" "apellidos" => "Chiapas-Gasca" ] 3 => array:2 [ "nombre" => "Juan J." "apellidos" => "Canoso" ] 4 => array:2 [ "nombre" => "Cristina" "apellidos" => "Hernández-Díaz" ] 5 => array:2 [ "nombre" => "Miguel Ángel" "apellidos" => "Saavedra" ] 6 => array:2 [ "nombre" => "José Eduardo" "apellidos" => "Navarro-Zarza" ] 7 => array:2 [ "nombre" => "Robert A." "apellidos" => "Kalish" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12002471?idApp=UINPBA00004M" "url" => "/1699258X/00000008000000S2/v1_201305061530/S1699258X12002471/v1_201305061530/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "titulo" => "Clinical Anatomy of the Hand" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "25" "paginaFinal" => "32" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Angélica Vargas, Karla Chiapas-Gasca, Cristina Hernández-Díaz, Juan J. Canoso, Miguel Ángel Saavedra, José Eduardo Navarro-Zarza, Pablo Villaseñor-Ovies, Robert A. Kalish" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Angélica" "apellidos" => "Vargas" "email" => array:1 [ 0 => "vargasgan@yahoo.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] 2 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Karla" "apellidos" => "Chiapas-Gasca" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] 2 => array:3 [ "nombre" => "Cristina" "apellidos" => "Hernández-Díaz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] 3 => array:3 [ "nombre" => "Juan J." "apellidos" => "Canoso" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] 2 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] 4 => array:3 [ "nombre" => "Miguel Ángel" "apellidos" => "Saavedra" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] 1 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] 5 => array:3 [ "nombre" => "José Eduardo" "apellidos" => "Navarro-Zarza" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] 1 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] 6 => array:3 [ "nombre" => "Pablo" "apellidos" => "Villaseñor-Ovies" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] 1 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] 7 => array:3 [ "nombre" => "Robert A." "apellidos" => "Kalish" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] 1 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] ] "afiliaciones" => array:9 [ 0 => array:3 [ "entidad" => "Rheumatology Department, National Institute of Cardiology, Mexico City, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Musculoskeletal Ultrasonography Laboratory Department, National Institute of Rehabilitation, Mexico City, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Musculoskeletal Ultrasonography Laboratory Department, National Institute of Rehabilitation, Mexico City, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "ABC Medical Center, Mexico City, Mexico" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Tufts University School of Medicine, Boston, MA, United States" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Rheumatology Department, La Raza National Medical Center, Mexico City, Mexico" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Hospital General de Chilpancingo Dr. Raymundo Abarca Alarcón, Chilpancingo, Guerrero, Mexico" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Rheumatologist, Tijuana, Mexico" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Mexican Group for the Study of Clinical Anatomy (GMAC), Mexico" "etiqueta" => "i" "identificador" => "aff0045" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anatomía clínica de la mano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0045" "etiqueta" => "Fig. 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 609 "Ancho" => 1174 "Tamanyo" => 121603 ] ] "descripcion" => array:1 [ "en" => "The dorsal fibrous tunnels are shown. An important landmark is the dorsal tubercle of radius (Lister's tubercle) which lies radial to extensor pollicis longus (EPL). This is a frequent site of tendon rupture in rheumatoid arthritis. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.22, with permission." ] ] ] "textoCompleto" => "General ConsiderationsThe hand is arranged along 5 rays that in full extension spread apart and in full flexion come together without overlaps, except the thumb, and with an admirable surface economy. The basis of this arrangement is a fixed dorsal convexity of the distal carpal row that translates to the metacarpals and from these to the phalanges. In addition, grasp activities depend on a fixed ratio of 1:1.6 for each segment of a digital ray as compared to its proximal fellow. This provides a perfect adaptability of the fingers for all diameters of an object.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> For the fingers 2–5 passive lateral motions are possible having the hand flat. However, progressive flexion of the MCP causes progressive loss of this motion so that at 90 degrees flexion lateral motions are no longer possible. This is due to the eccentricity of the medial and lateral collateral ligaments of the MCP joint (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In rheumatoid arthritis, chronic inflammation may damage the capsular tissues resulting in an unstable finger at full flexion of the MCP joint. The thumb MCP has no lateral motion in full extension and full flexion but is more than rewarded by the CMC (trapezium-metacarpal) motion that allows a boom-like swing of the metacarpal while preserving the flexion and extension movements of the thumb. Additionally, the thumb CMC exhibits a counter-clockwise rotation – as looked from proximal to distal – which makes the alignment of the thumb nail to the finger nails progressively more perfect as the little finger is approached. A disservice to the hand has been to depict it as a flat structure, thumb out, as in the dissection table. In the real state, as we all know, the wrist is slightly dorsiflexed, the MCFs and the IFs slightly flexed, and the 1st web at about 90 degrees to the other web spaces. Strength and precision are attributes of the human hand. Strength is delivered primarily by the long flexors and extensors, but a hand without intrinsic muscles, while maintaining its strength, is only useful as a hook.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The wrist, which is part of the hand, allows the hand to work in extension, in flexion and in ulnar and radial deviation. But the all-important forearm pronation and supination are provided by the distal radioulnar joint, the humeroradial and, to a lesser extent, the humeroulnar joints. The neutral position of the wrist is thumb up. In pronation, or palm down, the distal ulnar head becomes more prominent while the radius, with the triangular ligament attached, has fallen palm down. This makes the extensor carpi ulnaris (ECU) tendon to appear in the ulnarmost portion of the wrist. Once again thumb up, the ECU tendon is felt to overlap dorsally the distal ulnar head. Now in supination, or palm up, the ECU tendon appears between the distal ulnar head and the radius. The cases that follow highlight clinically relevant aspects of the hand that are only rarely discussed during rheumatology training.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Patient 1. Trigger finger“A 56 year-old man has a trigger finger”Patient 2. Trigger thumb“A 50 year-old woman has a trigger thumb”Patient 3. Rheumatoid flexor tenosynovitis“A 32 year-old woman with insufficiently treated rheumatoid arthritis has pain and swelling in the left index finger which cannot actively reach the palm”Relevant Anatomy Amenable to Self and Cross RecognitionCases 1, 2 and 3 focus our attention on the digital flexor sheaths, which comprise fibrous and synovial structures, and highlight the important role of the palmar creases both in diagnosis and as a guide for corticosteroid injections in flexor tenosynovial conditions.Palmar FasciaThe palmar fascia is a triangle shaped, tough sheet of connective tissue placed deep to the skin in the palm of the hand (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Ulnarly it is limited by the hypothenar muscles and laterally by the thenar muscles. Skin displacement during grip is prevented by fibrovascular septae with loculated fat in between that link the skin to the palmar fascia. This arrangement resembles closely to the plantar fat pad.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> In addition, seven sagittal ligaments join the palmar fascia to the deep metacarpals fascia and result in 8 tunnels, 4 for the flexor tendons and 4 for the lumbricals<a class="elsevierStyleCrossRef" href="#bib0025">5</a> distal to the central compartment of the hand. The superficial fibers of the palmar fascia fan out from palmaris longus and continue in the fingers as the pretendinous band, the spiral fibers and the lateral digital sheet. All of these structures, as well as the vertical septae that link the palmar fascia to the skin, are important in the pathogenesis of Dupuytren's contracture.<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> The deep fibers are generally transverse and can be considered an extension of the transverse carpal ligament into the palm. The fascia that covers the thenar and hypothenar muscles,<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> in contrast to the thick and complex palmar fascia, is thin and adherent to muscle. There is a superficial, transverse muscle that can be seen to bulge in the hypothenar eminence which originates in the palmar fascia and inserts in the skin. This is palmaris brevis.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The function of this peculiar muscle is conjectural. On the one hand it deepens the cupping of the hand when we drink from it. Also, it contracts synergistically then the 5th MCP is flexed with the PIP and the DIP in extension and during the abduction of the 5th digit.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Digital Flexor SheathsParticipants will have traced on their hands the full length of the digital flexor sheaths. They should understand the role of the restraining fibrous structures that maintain the tendons in close vicinity to bone and prevent bowstringing during flexion of the digits, the anular and cruciform pulleys.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Although pulleys are discontinuous when the fingers are extended, with synovial tissue in between, they come together and form an almost continuous tube when the fingers are flexed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The A1 pulley, being the most proximal and therefore the one that deflects the flexor tendons is the one that stands the greatest tendon/pulley pressures. Resulting swelling and chondroid changes in both the pulley and the tendon lead to nodule formation and the trigger phenomenon.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Although patients sometimes perceive the entrapment elsewhere the trigger phenomenon is an A1 pulley affair. Because finger flexor muscles are stronger than extensors trigger fingers are usually caught in flexion. A permanent flexor deformity may result in late, unrelieved cases. An additional restraining fibrous structure is the palmar aponeurosis pulley which is comprised of transverse fibers of the palmar fascia. This restraint, which is of marginal importance in normals, helps at preventing bowstringing when the A1 or the A2 pulley is cut. The thumb has 3 anular pulleys and an oblique pulley. The thumb A1 pulley, as in the fingers, overlaps the MCP joint.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The correct diagnosis in our patients is a trigger finger in Patient 1 and a trigger thumb in Patient 2. We would like to add that when the MCP joint ligaments are weakened, as in rheumatoid arthritis, the pull of the A1 pulley on the palmar plate and the base of the proximal phalanx in forceful finger flexion may be such as to cause palmar subluxation of the joint.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Proximal Extension of the Flexor Synovial SheathsThe proximal extension of the synovial flexor tendon sheaths, which are contained in the digital flexor sheaths, will now be shown (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). It is often surprising that the synovial sheath of the little finger connects with the ulnar bursa, a synovial expansion deep in the palm, in over 70% of cases.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> This three-layered structure, which provides a gliding surface between the long and short fingers flexors, as well as a gliding surface deep and superficial to these tendons, extends into the carpal tunnel and for about 2.5cm into the distal forearm. The synovial sheath of the long flexor of the thumb, also known as radial bursa, also traverses the palm and the carpal tunnel and extends into the distal forearm. In contrast, the synovial sheaths of the flexor tendons 2–4 end in the palmar space just short of the A1 pulley at the neck of the metacarpal bones. In Patient 3 the diagnosis is a rheumatoid flexor tenosynovitis. In this condition the swelling, which is due to both tenosynovial proliferation and effusion, involves the finger and the distal portion of the palm. Rheumatoid tenosynovitis may present few local findings but it must be suspected when a rheumatoid patient cannot actively make a full fist but passively the affected fingers can be painlessly flexed. The swelling tends to be diffuse and distend, as in our patient, the palmar cul-de-sac. Needless to say, these patients greatly improve with a well-placed tenosynovial corticosteroid injection.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Palmar Creases and the A1 PulleyThe great British anatomist Frederick Wood Jones stated that creases are the joints of the skin.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Looking at the palm there are 2 transverse creases, the distal and the proximal (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The distal crease, arising in the ulnar side of the hand bends distally and ends in the 2nd web space. The proximal crease begins with the longitudinal thenar crease in the 1st web space and ends short of the hypothenar eminence. An amazing phenomenon occurs when the straight fingers are bent 90 degrees at the MCP joints. Both the distal and the proximal crease come together in a continuous transverse crease. A cord placed in this crease indicates the proximal edge of the A1 pulley for the fingers 2–5. Deeper structures overlied by this cord include the flexor tendons, the palmar plates, the deep intermetacarpal ligaments that link neighboring palmar plates, and the MCP joints. Look at this region, known as region V or metacarpophalangeal by hand surgeons, from the palm, the radial side and the dorsum to get an idea of its complexity. More distally in the palmar side there is a crease where the finger appears to arise, the proximal digital crease. However, a cord placed around the finger at this crease, looked from the dorsum, crosses the mid portion of the proximal phalanx. Finally, a cord placed around the mid and the distal digital creases roughly overlaps the PIP and the DIP joints, respectively.The Palmar Plates and the Deep Intermetacarpal LigamentThe palmar plates are thick and dense plates – whether they are fibrocartilaginous or not is in debate – that reinforce the volar aspect of the MCP joints (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). While distally the palmar plates are firmly attached to the proximal phalanx, proximally they become a thin, membranous capsule.<a class="elsevierStyleCrossRefs" href="#bib0080">16,17</a> Each palmar plate is connected to the neighboring palmar plates by the deep intermetacarpal ligament. Also, sagittal bands (SB) connect the extensor tendon to the edges of the palmar plates, which also give insertion to the accessory MCP lateral collateral ligament and the A1 pulley. Thus, the palmar plates provide a true anchoring system to the fibrous skeleton of the MCP region. Together, the SBs and the palmar plate form a closed cylindrical tube that surrounds the metacarpal head. It is considered that the SBs represent the main stabilizer of the extensor tendon at the MCP joint.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Damage of the radial sagittal fibers is one of the factors leading to ulnar deviation in rheumatoid arthritis. Palmar plates with a similar phalangeal attachment are also present in the interphalangeal joints.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>Corticosteroid Infiltration in Trigger Finger/Thumb and TenosynovitisIn Patient 1 the injecting needle is placed just distal to the proximal transverse crease for the index, between the proximal and distal creases for the middle finger and just distal to the distal crease for the anular and the little finger. There is no need to place the steroid within the synovial sheath in this condition. Indeed, extrasynovial injections appear to work better. The injection for the trigger thumb is quite different and the thumb sesamoids are used as a landmark. The thumb has 2 sesamoid bones which are easily palpable at the base of the thumb on the flexor side. These tiny bones transmit force from the abductor pollicis and the flexor pollicis brevis to the proximal phalanx via the volar plate. They also guide the flexor pollicis longus tendon that lies between them.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> The thumb sesamoids vary in size among people and one may be larger than the other. The sesamoids area is normally tender to palpation. The injecting needle is aimed at the sesamoids (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). In Patient 3, with a diagnosis of rheumatoid flexor tenosynovitis, it is quite important to place the steroid within the sheath because synovial tissue is interspersed between pulleys and at both ends of the tube. An intrasynovial injection is felt by the patient as fluid extending distally along the palmar aspect of the finger.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>Practical Review of Some Palmar Structures<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Palmar creases</li><li class="elsevierStyleListItem" id="lsti0010">•Dorsal projection of proximal digital crease</li><li class="elsevierStyleListItem" id="lsti0015">•Palmaris brevis muscle</li><li class="elsevierStyleListItem" id="lsti0020">•Palmar fascia and its longitudinal and transverse components (superficial transverse metacarpal ligament, longitudinal and transverse fascicles)</li><li class="elsevierStyleListItem" id="lsti0025">•Digital pulleys</li><li class="elsevierStyleListItem" id="lsti0030">•Flexor synovial sheaths</li><li class="elsevierStyleListItem" id="lsti0035">•Flexor tendons</li><li class="elsevierStyleListItem" id="lsti0040">•Palmar plates, approximate position</li><li class="elsevierStyleListItem" id="lsti0045">•Thumb sesamoids</li><li class="elsevierStyleListItem" id="lsti0050">•Tendons that are contained in the carpal tunnel</li></ul>Patient 4. Interosseous muscle function“A fellow is asked during the certifying examination: Which muscles separate the fingers and which muscles bring them together? He pales and looks at the examiner in disbelief”.Relevant Anatomy Amenable to Self and Cross RecognitionThe Extensor LaminaIf we overstretch the fingers the extensor tendons, prominent in the dorsum of the hand, are seen to disappear at the fingers. One of the reasons of this phenomenon is that the extensor tendon itself is anchored by sagittal fibers to the palmar cartilaginous plate that reinforces the MCP on the palmar side.<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> A second reason is that the extensor tendon becomes embedded in the dorsal digital expansion.<a class="elsevierStyleCrossRefs" href="#bib0115">23–25</a> The dorsal digital expansion may be viewed as an isosceles triangle applied on the proximal phalanx (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). The expansion incorporates the central tendon fibers destined to the base of the middle phalanx. In addition, it contains two previously separated extensor tendon contingents, the radial and the ulnar lateral bands, that join together prior to their destination at the base of the distal phalanx. Also, the interossei muscles as well as the lumbricals, past the deep transverse metacarpal ligament that separates them, run toward the angles of the extensor lamina and once incorporated to this structure, extend along the lateral sides in the middle and lateral conjoined tendons.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In finger flexion the lateral bands slide palmarly over the PIP joint while in extension the tendon pull brings them closer together as to better extend the DIP joint.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Is it possible to palpate the extensor lamina? Yes, by 2-finger palpation, one radial and one ulnar, on the dorsolateral aspect of the proximal phalanx during flexion-extension movements. Is it important? Yes, to get a dynamic idea of what it is going on.<elsevierMultimedia ident="fig0030"></elsevierMultimedia>The Dorsal Interosseus MusclesThe interosseal muscles, both the dorsal and the palmar (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>), have their origin in the metacarpals and insert at the corners of the extensor lamina. In addition, the dorsal interossei have a point of insertion in the proximal phalanx.<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a> Both sets of muscles run dorsal to de deep intermetacarpal ligament. The longitudinal axis of the hand is comprised of the long finger and the 3rd metacarpal. Proof of this is that the 3erd digit stays still when the fingers are spread apart and when they are brought back together. While the dorsal interosseus tendons are so placed as to separate the index and the anular away from the long finger, by having 2 dorsal interossei this finger is able to separate from its own axis to the ulnar and the radial sides. The separation of the little finger is achieved primarily by the abductor digiti minimi and the separation of the thumb primarily by the abductor pollicis brevis. Are the bellies of the dorsal interossei identifiable on examination? The answer is a timid yes for the interossei of the long and anular fingers (you can feel them hardening during abduction with a finger appropriately placed on the dorsum of the hand) and a rotund yes for the index dorsal interosseus. This muscle is eminently placed, as well as distinctly developed in normal subjects, as to allow its clinical identification and functional characterization far beyond dissection.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> An experiment can be made “in vivo” by looking at the radial side of the 2nd MCP joint which is free of an overlapping finger. With the tip of a ballpen is possible to identify a point that remains still during flexion-extension movements. This is the transverse axis of the MCP joint. Now let's abduct the index. This motion brings up a strong muscle belly in the web space, which is no other than the dorsal interosseus muscle. If the free edge of this muscle is followed toward the index a tiny tendon appears to attach to the proximal phalanx (in most cases the attachment is to both bone and the dorsal lamina) about 1cm palmar to the axis point which explains its flexor action on the MCP joint. Furthermore, through the dorsal lamina the same contraction extend the interphalangeal joints. Variations are common in the dorsal interossei.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> All dorsal interossei are innervated by the ulnar nerve.<elsevierMultimedia ident="fig0035"></elsevierMultimedia>The Palmar Interosseus MusclesThere are 3 palmar interosseous muscles (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>), one for the index, one for the anular and 1 for the little finger.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> These muscles, similar to the dorsal counterparts, insert near the corner of the dorsal lamina, on the opposite side. With their origins and insertions facing the long finger it is easy to appreciate that they function as adductors, i.e. they bring the fingers close together. Their actions on the transverse axis of the joints are the same as in the dorsal interossei, flexion of the MCP joint and extension of the PIP and DIP joints. The palmar interossei cannot be reliably identified by palpation. Anatomical variations in these muscles are common.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> All palmar interossei are innervated by the ulnar nerve. Before leaving the interosseous muscles let's make one more experiment. Please note that adduction and abduction of the fingers have been tested in extension. How about with the MCP joints flexed 90 degrees? These motions are not possible. Is this due to the characteristics of insertion of the interosseal muscles? The answer is not, as passive motion is also canceled. The reason for the inability to abduct and adduct the fingers is the eccentric nature of the collateral ligaments of the MCP joints. They are lax in extension and taut in flexion. In rheumatoid arthritis, where damage to the MCP collateral ligaments may occur, lateral finger motion at 90 degrees of MCP flexion is a reliable indicator of this lesion.The Lumbrical MusclesThese unique muscles that really look like earthworms have their origin in the deep flexor tendons in the palm of the hand (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>).<a class="elsevierStyleCrossRefs" href="#bib0150">30,31</a> In their way to the extensor lamina they run palmar to the deep metacarpal ligament.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> A unique characteristic of the lumbrical muscles is that, having had an origin in a flexor muscle their insertion is in the extensor lamina and therefore their main action is to flex the MCP joints while extending the PIP and DIP joints. This flexor/extensor linkage, an abundance of mechanoreceptors, plus a common innervation with the flexor digitorum profundus (index and middle finger, median nerve; ring and small finger, ulnar nerve) is telling us something in a language we still do not understand. Variations in the lumbrical muscles are frequent.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> One such variation that may cause a carpal tunnel syndrome is an origin within the carpal tunnel. An origin in the forearm has also been described.<elsevierMultimedia ident="fig0040"></elsevierMultimedia>Patient 5. De Quervain's tenosynovitis.“A 79-year old violist presents with severe pain in the radial side of his wrist. He is due to play in a concert in 2 days. On physical examination there is a bulky trapeziometacarpal osteoarthritis. He has a markedly positive Finkelstein test. What am I supposed to do? This patient exemplifies a common clinical situation. When there are concurrent conditions, which one is causing the pain? One of his conditions is known to be rather refractory to treatment, the osteoarthritis. The other, de Quervain's tenosynovitis, is eminently treatable by a steroid infiltration. This dilemma was presented to the patient and he had no doubts about the correct course of action which was to have the 1st dorsal compartment tenosynovial sheath injected. The infiltration was successful and he was able to play at his concert”.Relevant Anatomy Amenable to Self and Cross RecognitionThe Extensor Retinaculum and the Dorsal Tendon CompartmentsContinuing with our cord experiments, if we place a cord at the distal wrist crease, on the palmar side the cord indicates the proximal limit of the transverse palmar ligament and on the dorsum, the distal limit of the extensor retinaculum (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>). Thus, the extensor retinaculum is a forearm extensor tendon restraint and the transverse carpal ligament is a wrist flexor tendon restraint. This concept is critical to an understanding of the contents of the radial-most tendon compartments:first dorsal compartment, abductor pollicis longus (APL) and extensor pollicis brevis (EPB); second compartment, extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB); and third compartment, extensor pollicis longus (EPL). Moving distally, at the wrist the first compartment tendons remain the same, but they are followed by EPL and then ECRL and ECRB. The reason for this transposition is an oblique course of EPL at the wrist. Going back to the extensor retinaculum, EPL is flanked radially by a bony eminence, the dorsal tubercle of radius or Lister's tubercle, that redirects its course. The fourth compartment contains extensor indicis (EI) and extendor digitorum (ED). The fifth compartment, which is easy to locate between the distal end of ulna and the radius contains extensor digiti minimi (EDM) and the sixth and compartment, extensor carpi ulnaris. At the first compartment both APL and EPB may have multiple slips In addition, a septum and a bone ridge may be present in 30%–40% between the APL and the EPB tendons.<a class="elsevierStyleCrossRef" href="#bib0165">33</a><elsevierMultimedia ident="fig0045"></elsevierMultimedia>Forearm Intersection SyndromeA unique pain syndrome may occur after heavy labor, the intersection syndrome of the forearm.<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a> Pain, tenderness and swelling occur dorso-radially in the forearm about 4 FB proximal to Lister's tubercle. A diagnostic sign is a tendon friction rub brought about by thumb abduction and flexion-extension movements of the wrist. A simple maneuver reveals the anatomy of this condition. Place 4 fingers on the wrist and distal forearm, the little finger next to the base of the 2nd and 3rd metacarpals, the anular over Lister's tubercle, and the long finger and the index proximal to the latter. Now ask the patient to gently dorsiflex the wrist. The tension of the ECRL and ECRB will be felt with the little finger and less with the other fingers. Let's now ask the patient to abduct the thumb. The APL and EPB will be tense up and this will be felt by the index but not by the other digits. Indeed, if one runs the index proximally over the radius these muscles will be felt to run obliquely over a generally longitudinal background. To summarize, APL and EPB cross superficially over ECRL and ECRL A rheumatologist with an interest in clinical anatomy should be able to make an instant diagnosis of intersection syndrome. Someone less informed may require an MRI or an ultrasonography study.Practical Review of Some Dorsal Structures<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0055">•Palpation of the extensor lamina</li><li class="elsevierStyleListItem" id="lsti0060">•Palpation of dorsal interossei</li><li class="elsevierStyleListItem" id="lsti0065">•Action of dorsal interossei</li><li class="elsevierStyleListItem" id="lsti0070">•Action of palmar interossei</li><li class="elsevierStyleListItem" id="lsti0075">•Why interossei flex the MCP (review of the insertion of the 1st dorsal interosseus muscle)</li><li class="elsevierStyleListItem" id="lsti0080">•Lumbricals action</li><li class="elsevierStyleListItem" id="lsti0085">•Palpatory recognition of trapezium, scaphoid, head of capitate, radial styloid, distal radius, Lister's tubercle (dorsal radial tubercle), distal ulna, ulnar styloid</li><li class="elsevierStyleListItem" id="lsti0090">•Visual and palpatory recognition of tendons at the dorsal wrist. From radial to ulnar:abductor pollicis longus (APL), extensor pollicis brevis (APB), extensor pollicis longus (EPL), extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor indicis (EI), extensor digitorum (ED), extensor digiti minimi (EDM), and extensor carpi ulnaris (ECU)</li><li class="elsevierStyleListItem" id="lsti0095">•Anatomical snuffbox (APL, EPB, radial styloid, radius, Lister's tubercle, scaphoid, trapezium, radial artery, EPL)</li><li class="elsevierStyleListItem" id="lsti0100">•Distal boundary of extensor retinaculum</li><li class="elsevierStyleListItem" id="lsti0105">•Intersection site, recognition by palpation of APL and EPB, ECRL and ECRB</li><li class="elsevierStyleListItem" id="lsti0110">•Finkelstein's maneuver</li></ul>Patient 6. Carpal tunnel syndrome.“A 46 year-old woman with rheumatoid arthritis. She has tingling in her hands, decreased pin prick sensation in her thumb and index and early atrophy of abductor pollicis brevis”Relevant Anatomy Amenable to Self and Cross RecognitionTransverse carpal ligament. This ligament, also known as flexor retinaculum, binds anteriorly the carpal tunnel (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4 and 10</a>). Its main insertions, on the radial side, are the tubercle of scaphoid and the crest of the trapezium.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> The ulnar side insertions include the pisiform and the hook of hamate. The latter lies deep and can be distinguished only in thin people with supple hands. As mentioned, a string placed at the distal anterior wrist crease indicates the proximal border of the transverse carpal ligament. Nine tendons are contained within the carpal tunnel: four flexor digitorum superficialis tendons, four flexor digitorum profundus tendons and flexor pollicis longus tendon.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> Within the tunnel the 3 synovial tongues that make up the ulnar bursa separate the anterior carpal ligament from the superficial flexor tendons, the superficial from the deep flexor tendons, and the deep flexor tendons from the carpal ligaments and bones. On the radial side the synovial sheath of flexor pollicis longus, known as radial bursa, partially surrounds this tendon on its radial, anterior and posterior sides. The median nerve was left to last because it lies superficially in the boundary between the radial and the ulnar bursae. The subsynovial tissue, as in other connective tissues that glide upon each other, has a complex microstructural arrangement.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> In addition, it may act as a barrier to diffusion.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> The flexor tendons and the median nerve cannot be palpated while in the carpal tunnel. Tissues are just too tightly packed, the anterior carpal ligament is thick and the inserting thenar and hypothenas muscles almost reach each other anterior to the ligament. The distal edge of the transverse carpal ligament cannot be felt as it blends imperceptively with the palmar fascia.<elsevierMultimedia ident="fig0050"></elsevierMultimedia>Guyon's canal. Guyon's canal is placed anteriorly in the ulnar third of the wrist. This canal has a proximal opening for the ulnar nerve and artery and 2 distal openings, one for the deep (motor) branch of the ulnar nerve and its artery and another for the superficial (sensory) branch of the ulnar nerve and its artery. Gross and Gelberman have recognized 3 distinct zones in this region, zone 1 in which the nerve is still undivided, zone 2 that refers to the opening for the motor branch, and zone 3 that relates to the superficial branch.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> The roof of Guyon's canal includes the palmar carpal ligament in zone 1, palmaris brevis muscle in zone 2 and fat and fibrous tissue in zone 3. An important point in surface innervation is that the radial half of the palm is supplied by the palmar cutaneous branch of the median nerve and its ulnar half, by the palmar cutaneous branch of the ulnar nerve. Both of these branches arise from the corresponding nerves in the distal forearm and being anterior to the transverse ligamentous structures they are not compressed in the carpal tunnel syndrome and the Guyon's canal syndrome.<a class="elsevierStyleCrossRef" href="#bib0205">41</a>Tendon boundaries of the median nerve at the distal forearm. As mentioned, the median nerve runs deep into, and in between, palmaris longus and flexor carpi radialis. The ulnar bursa, covering the flexor tendons, extends 2–2.5cm proximal to the transverse carpal ligament. This synovial extension allows the injection of the largest synovial structure within the carpal tunnel proximal to the tight limits of the tunnel. The radial bursa, which underlies flexor carpi radialis, is a much smaller than the ulnar bursa. It makes sense to inject the larger rather than the smaller synovial structure hoping that volume reduction after the corticosteroid injection would be greater. We use a needle entry medial to palmaris longus, 1.5–2cm proximal to the distal flexor crease, with a distal angulation of 45 degrees (<a class="elsevierStyleCrossRef" href="#fig0055">Fig. 11</a>). Free flow of the local anesthetic without creating a collection indicates a correct placement. Of course, the median nerve and an important branch, the anterior interosseal nerve, as well as the ulnar nerve counterparts, may be compressed more proximally in the forearm.<a class="elsevierStyleCrossRefs" href="#bib0205">41,42</a><elsevierMultimedia ident="fig0055"></elsevierMultimedia>Practical Review of the Carpal Tunnel and Related Anatomical Structures<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0115">•Thumb movements in the functional position of the hand</li><li class="elsevierStyleListItem" id="lsti0120">•Thenar eminence muscles</li><li class="elsevierStyleListItem" id="lsti0125">•Median nerve</li><li class="elsevierStyleListItem" id="lsti0130">•Hypothenar eminence</li><li class="elsevierStyleListItem" id="lsti0135">•Palmar cutaneous muscle, why is it there and how to demonstrate it</li><li class="elsevierStyleListItem" id="lsti0140">•Guyon's canal</li><li class="elsevierStyleListItem" id="lsti0145">•Transverse carpal ligament and its insertions</li><li class="elsevierStyleListItem" id="lsti0150">•Flexor carpi radialis longus</li><li class="elsevierStyleListItem" id="lsti0155">•Palmaris muscle</li><li class="elsevierStyleListItem" id="lsti0160">•Flexor carpi radialis</li><li class="elsevierStyleListItem" id="lsti0165">•Ulnar bursa (in the palm, the carpal tunnel and the distal forearm)</li><li class="elsevierStyleListItem" id="lsti0170">•Tinel's and Phalen's maneuvers</li></ul>Conflict of InterestThe authors have no conflict of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres124088" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec111370" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres124089" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec111371" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "General Considerations" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Relevant Anatomy Amenable to Self and Cross Recognition" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Palmar Fascia" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Digital Flexor Sheaths" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Proximal Extension of the Flexor Synovial Sheaths" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Palmar Creases and the A1 Pulley" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "The Palmar Plates and the Deep Intermetacarpal Ligament" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Corticosteroid Infiltration in Trigger Finger/Thumb and Tenosynovitis" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Practical Review of Some Palmar Structures" ] 7 => array:3 [ "identificador" => "sec0050" "titulo" => "Relevant Anatomy Amenable to Self and Cross Recognition" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "The Extensor Lamina" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "The Dorsal Interosseus Muscles" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "The Palmar Interosseus Muscles" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "The Lumbrical Muscles" ] ] ] 8 => array:3 [ "identificador" => "sec0075" "titulo" => "Relevant Anatomy Amenable to Self and Cross Recognition" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "The Extensor Retinaculum and the Dorsal Tendon Compartments" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Forearm Intersection Syndrome" ] ] ] 9 => array:2 [ "identificador" => "sec0090" "titulo" => "Practical Review of Some Dorsal Structures" ] 10 => array:2 [ "identificador" => "sec0095" "titulo" => "Relevant Anatomy Amenable to Self and Cross Recognition" ] 11 => array:2 [ "identificador" => "sec0100" "titulo" => "Practical Review of the Carpal Tunnel and Related Anatomical Structures" ] 12 => array:2 [ "identificador" => "sec0105" "titulo" => "Conflict of Interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-10-04" "fechaAceptado" => "2012-10-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec111370" "palabras" => array:8 [ 0 => "Hand" 1 => "Trigger finger" 2 => "Trigger thumb" 3 => "Rheumatoid flexor tenosynovitis" 4 => "Interosseus muscles" 5 => "Lumbrical muscles" 6 => "De Quervain's tenosynovitis" 7 => "Carpal tunnel syndrome" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec111371" "palabras" => array:8 [ 0 => "Mano" 1 => "Dedo en gatillo" 2 => "Pulgar en gatillo" 3 => "Tenosinovitis flexora reumatoidea" 4 => "Músculos interóseos" 5 => "Músculos lumbricales" 6 => "Tenosinovitis de De Quervain" 7 => "Síndrome del tunel del carpo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "This article reviews the underlying anatomy of trigger finger and thumb (fibrous digital pulleys, sesamoid bones), flexor tenosynovitis, de Quervain's syndrome, Dupuytren's contracture, some hand deformities in rheumatoid arthritis, the carpal tunnel syndrome and the ulnar nerve compression at Guyon's canal. Some important syndromes and structures have not been included but such are the nature of these seminars. Rather than being complete, we aim at creating a system in which clinical cases are used to highlight the pertinent anatomy and, in the most important part of the seminar, these pertinent items are demonstrated by cross examination of participants and teachers. Self learning is critical for generating interest and expanding knowledge of clinical anatomy. Just look at your own hand in various positions, move it, feel it, feel also your forearms while you move the fingers, do this repeatedly and inquisitively and after a few tries you will have developed not only a taste, but also a lifelong interest in clinical anatomy." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "En este artículo revisa la anatomía subyacente en el dedo en gatillo y el pulgar en gatillo (poleas digitales fibrosas, huesos sesamoideos), tenosinovitis flexora, síndrome de De Quervain, contractura de Dupuytren, algunas deformidades de la mano en la artritis reumatoide, el síndrome del túnel carpiano y la compresión del nervio cubital en el canal de Guyon. Debido a la naturaleza de estos seminarios, no se han incluido algunos síndromes importantes y estructuras. Más que ser exhaustivos, nuestro objetivo es crear un sistema en el que los casos clínicos se utilizan para resaltar la anatomía pertinente y, en la parte más importante del seminario, estos elementos se muestran a partir de una examen cruzado entre participantes y profesores. El autoaprendizaje es fundamental para generar interés y ampliar el conocimiento de la anatomía clínica. Basta con mirarse las propias manos en distintas posturas, moverlas, sentirlas; sientan también el antebrazo mientras mueven los dedos, háganlo varias veces, con espiritu de indagación, y tras unos pocos intentos no solo habrán adquirido un gusto, sino un interés por la anatomía clínica." ] ] "multimedia" => array:11 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1318 "Ancho" => 1275 "Tamanyo" => 121909 ] ] "descripcion" => array:1 [ "en" => "Upper panel. MCP joint showing the metacarpophalangeal joint (MCP) in neutral. The collateral ligament is relaxed. Note tibrocartilaginous palmar plate in the palmar aspect of the joint. Lower panel. The lateral collateral ligament becomes taut in flexion. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.16, with permission." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2492 "Ancho" => 1544 "Tamanyo" => 413958 ] ] "descripcion" => array:1 [ "en" => "(a) The palmar fascia. The longitudinal fibers derive from palmaris longus tendon. Note the transverse fibers of palmaris brevis, a subcutaneous musle at the hypothenar eminence. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.16, with permission. (b) A transverse section of the hand. The palmar fascia is located near the palmar surface. It is connected to the dermis by fibrous strands that loculate tiny fat lobules. Septae connect the deep aspect of the palmar fascia to the deep fascia that overlies the metacarpals and the interosseous muscles (the insert shows the site of the section). From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.16, with permission." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1080 "Ancho" => 1048 "Tamanyo" => 89570 ] ] "descripcion" => array:1 [ "en" => "This is a simplified rendition of the fibrous digital pulleys. The proximal pulley, A1, inserts in the palmar plate and in the transverse metacarpal ligament that binds neighboring palmar plates. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.22, with permission." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1197 "Ancho" => 808 "Tamanyo" => 171511 ] ] "descripcion" => array:1 [ "en" => "This figure shows the relationship between the transverse palmar creases and the flexor synovial sheaths. Note that for the digits 2,3,4 the synovial sheaths end near the transverse creases. For the thumb and the small finger the sheaths extend to the distal forearm. The expansion of the latter in the mid palm is the ulnar bursa, a synovial structure extends to the carpal tunnel and the distal forearm. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.24, with permission." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 530 "Ancho" => 750 "Tamanyo" => 72800 ] ] "descripcion" => array:1 [ "en" => "In the trigger thumb the needle is inserted toward the sesamoid bones, which coincide with the proximal anular pulley of the thumb." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 731 "Ancho" => 1361 "Tamanyo" => 123464 ] ] "descripcion" => array:1 [ "en" => "The extensor lamina is a triangular fibrous sheath in the dorsum of the proximal phalanx. The extensor tendon is incorporated into this lamina and the interosseous muscles and the lumbrical muscles attach to its sides. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.54, with permission." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 777 "Ancho" => 1672 "Tamanyo" => 175857 ] ] "descripcion" => array:1 [ "en" => "The left panel depicts the palmar interosseus muscles. These are three and given their disposition they bring the index, the anular and the little finger toward the 3rd finger which is the axis of the hand. The dorsal interosseus muscles are shown in the right panel. The middle finger has two and the anular and the index fingers have one. Their disposition is such that they separate the fingers from the 3rd finger, and move the 3rd finger to one and the other side. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.20, with permission." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Fig. 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 922 "Ancho" => 1249 "Tamanyo" => 117279 ] ] "descripcion" => array:1 [ "en" => "The lumbrical muscles are shown. They are palmar, while the dorsal and the palmar interossei are dorsal, to the transverse metacarpal ligament. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.20, with permission." ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Fig. 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 609 "Ancho" => 1174 "Tamanyo" => 121603 ] ] "descripcion" => array:1 [ "en" => "The dorsal fibrous tunnels are shown. An important landmark is the dorsal tubercle of radius (Lister's tubercle) which lies radial to extensor pollicis longus (EPL). This is a frequent site of tendon rupture in rheumatoid arthritis. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.22, with permission." ] ] 9 => array:7 [ "identificador" => "fig0050" "etiqueta" => "Fig. 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 712 "Ancho" => 1230 "Tamanyo" => 69479 ] ] "descripcion" => array:1 [ "en" => "This sketch depicts the four main osseous insertions of the transverse carpal ligament. This ligament binds anteriorly the carpal tunnel. From A Companion to Medical Studies, Volume 1, Ed. by Passmore R and Robson JS, 2nd Edition, Oxford, Wiley/Blackwell 1976, p. 23.22, with permission." ] ] 10 => array:7 [ "identificador" => "fig0055" "etiqueta" => "Fig. 11" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr11.jpeg" "Alto" => 563 "Ancho" => 750 "Tamanyo" => 97719 ] ] "descripcion" => array:1 [ "en" => "One of the techniques of infiltration in carpal tunnel syndrome is shown. The needle is inserted ulnar to the palmaris longus tendon 1.5–2cm proximal to the distal flexor crease of the wrist." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "On the adaptability of man's hand (with reference to the equiangular curve)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.W. Littler" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Hand" "fecha" => "1973" "volumen" => "5" "paginaInicial" => "187" "paginaFinal" => "191" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4583856" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The reconstruction of the hand in leprosy. Hunterian Lecture delivered at the Royal College of Surgeons of England" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P.W. Brand" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann R Coll Surg Engl" "fecha" => "1952" "volumen" => "11" "paginaInicial" => "350" "paginaFinal" => "361" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12996957" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The fascia of the limbs and back—a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Benjamin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1469-7580.2008.01011.x" "Revista" => array:6 [ "tituloSerie" => "J Anat" "fecha" => "2009" "volumen" => "214" "paginaInicial" => "1" "paginaFinal" => "18" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19166469" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Three-dimensional morphology of heel fat pad: an in vivo computed tomography study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "V. Campanelli" 1 => "M. Fantini" 2 => "N. Faccioli" 3 => "A. Cangemi" 4 => "A. Pozzo" 5 => "A. Sbarbati" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1469-7580.2011.01420.x" "Revista" => array:6 [ "tituloSerie" => "J Anat" "fecha" => "2011" "volumen" => "219" "paginaInicial" => "622" "paginaFinal" => "631" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21848602" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The palmar aponeurosis and the central spaces of the hand" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Bojsen-Møller" 1 => "L. Schmidt" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Anat" "fecha" => "1974" "volumen" => "117" "paginaInicial" => "55" "paginaFinal" => "68" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4844651" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dupuytren's contracture unfolded" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "W.A. Townley" 1 => "R. Baker" 2 => "N. Sheppard" 3 => "A.O. Grobbelaar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bmj.332.7538.397" "Revista" => array:6 [ "tituloSerie" => "BMJ" "fecha" => "2006" "volumen" => "332" "paginaInicial" => "397" "paginaFinal" => "400" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16484265" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scientific understanding and clinical management of Dupuytren disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B. Shih" 1 => "A. Bayat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/nrrheum.2010.180" "Revista" => array:6 [ "tituloSerie" => "Nat Rev Rheumatol" "fecha" => "2010" "volumen" => "6" "paginaInicial" => "715" "paginaFinal" => "726" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21060335" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomy and function of the thenar muscles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. Gupta" 1 => "H. Michelsen-Jost" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hcl.2011.09.006" "Revista" => array:6 [ "tituloSerie" => "Hand Clin" "fecha" => "2012" "volumen" => "28" "paginaInicial" => "1" "paginaFinal" => "7" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22117918" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomy and function of the hypothenar muscles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.A. Pasquella" 1 => "P. Levine" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hcl.2011.09.003" "Revista" => array:6 [ "tituloSerie" => "Hand Clin" "fecha" => "2012" "volumen" => "28" "paginaInicial" => "19" "paginaFinal" => "25" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22117921" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The palmaris brevis—a reconsideration of its anatomy and possible function" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.M. Shrewsbury" 1 => "R.K. Johnson" 2 => "D.K. Ousterhout" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Bone Joint Surg Am" "fecha" => "1972" "volumen" => "54" "paginaInicial" => "344" "paginaFinal" => "348" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4651265" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Palmar and digital flexor tendon pulleys" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.R. Doyle" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Orthop Rel Res" "fecha" => "2001" "volumen" => "383" "paginaInicial" => "84" "paginaFinal" => "96" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trigger finger and tendinosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.C. Lundin" 1 => "P. Eliasson" 2 => "P. Aspenberg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Hand Surg Eur" "fecha" => "2012" "volumen" => "37" "paginaInicial" => "233" "paginaFinal" => "236" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The pulley system of the thumb: anatomic and biomechanical study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Bayat" 1 => "H. Shaaban" 2 => "G. Giakas" 3 => "V.C. Lees" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Hand Surg Am" "fecha" => "2002" "volumen" => "27" "paginaInicial" => "628" "paginaFinal" => "635" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12132087" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tendon sheath patterns in the hand: an anatomical study based on 367 hand dissections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.W. Scheldrup" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Surg Gynecol Obstet" "fecha" => "1951" "volumen" => "93" "paginaInicial" => "16" "paginaFinal" => "22" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14855245" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Principles of Anatomy as Seen in the Hand" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F. Wood Jones" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "1949" "editorial" => "Baillière, Tindall and Cox" "editorialLocalizacion" => "London" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MR imaging of the metacarpophalangeal joints of the fingers: part I. Conventional MR imaging and MR arthrographic findings in cadavers" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N.H. Theumann" 1 => "C.W. Pfirrmann" 2 => "J.L. Drapé" 3 => "D.J. Trudell" 4 => "D. Resnick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.2222010181" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2002" "volumen" => "222" "paginaInicial" => "437" "paginaFinal" => "445" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11818611" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Metacarpophalangeal joints at US in asymptomatic volunteers and cadaveric specimens" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "N. Boutry" 1 => "A. Lardé" 2 => "X. Demondion" 3 => "B. Cortet" 4 => "H. Cotten" 5 => "A. Cotten" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.2323031075" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2004" "volumen" => "232" "paginaInicial" => "716" "paginaFinal" => "724" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15229348" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The sagittal band: anatomic and biomechanical study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.M. Young" 1 => "G.M. Rayan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/jhsu.2000.18495" "Revista" => array:6 [ "tituloSerie" => "J Hand Surg Am" "fecha" => "2000" "volumen" => "25" "paginaInicial" => "1107" "paginaFinal" => "1113" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11119670" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Proximal interphalangeal joint volar plate configuration in the crimp grip position" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Bayer" 1 => "A. Schweizer" 2 => "M. Müller-Gerbl" 3 => "G. Bongartz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jhsa.2012.02.016" "Revista" => array:6 [ "tituloSerie" => "J Hand Surg Am" "fecha" => "2012" "volumen" => "37" "paginaInicial" => "899" "paginaFinal" => "905" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22480508" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The sesamoids of the metacarpo-phalangeal joint of the thumb: an anatomical and clinical study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.D. Gibeault" 1 => "P. Saba" 2 => "H. Hoenecke" 3 => "A. Graham" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Hand Surg Br" "fecha" => "1989" "volumen" => "14" "paginaInicial" => "244" "paginaFinal" => "247" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2746129" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extensor mechanism of the fingers. MR Imaging-anatomic correlation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.A. Clavero" 1 => "P. Golanó" 2 => "O. Fariñas" 3 => "X. Alomar" 4 => "J.M. Monill" 5 => "M. Esplugas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/rg.233025079" "Revista" => array:6 [ "tituloSerie" => "Radiographics" "fecha" => "2003" "volumen" => "23" "paginaInicial" => "593" "paginaFinal" => "611" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12740463" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The thickness of the sagittal bands in volunteers: high resolution ultrasound of the fingers" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Kichouh" 1 => "M. De Maeseneer" 2 => "T. Jager" 3 => "S. Marcelis" 4 => "E. Van Hedent" 5 => "J. De Mey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00276-010-0693-6" "Revista" => array:6 [ "tituloSerie" => "Surg Radiol Anat" "fecha" => "2011" "volumen" => "33" "paginaInicial" => "65" "paginaFinal" => "70" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20632175" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The anatomy of the dorsal aponeurosis of the human finger and its functional significance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.N.F. Landsmeer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anat Rec" "fecha" => "1949" "volumen" => "104" "paginaInicial" => "31" "paginaFinal" => "44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18149912" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The extensor apparatus of the finger" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Wheeler Haines" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Anat" "fecha" => "1951" "volumen" => "85" "paginaInicial" => "251" "paginaFinal" => "259" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14850394" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The dorsal aponeurosis, intrinsic, hypothenar, and thenar musculature of the hand" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.P. von Schroeder" 1 => "M.J. Botte" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Orthop" "fecha" => "2001" "volumen" => "383" "paginaInicial" => "97" "paginaFinal" => "107" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11210974" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The functional anatomy of the extensor mechanism of the finger" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Harris Jr." 1 => "G.L. Rutledge Jr." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Bone Joint Surg" "fecha" => "1972" "volumen" => "54" "paginaInicial" => "713" "paginaFinal" => "726" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5055166" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomy of the intrinsic hand muscles revisited: part I. Interossei" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Eladoumikdachi" 1 => "P.L. Valkov" 2 => "J. Thomas" 3 => "D.T. Netscher" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.PRS.0000024442.72140.56" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2002" "volumen" => "110" "paginaInicial" => "1211" "paginaFinal" => "1224" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12360058" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The interosseous muscles: the foundation of hand function" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F.E. Liss" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hcl.2011.09.005" "Revista" => array:6 [ "tituloSerie" => "Hand Clin" "fecha" => "2012" "volumen" => "28" "paginaInicial" => "9" "paginaFinal" => "12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22117919" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Architectural properties of the first dorsal interosseous muscle" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.W. Infantolino" 1 => "J.H. Challis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1469-7580.2009.01196.x" "Revista" => array:6 [ "tituloSerie" => "J Anat" "fecha" => "2010" "volumen" => "216" "paginaInicial" => "463" "paginaFinal" => "469" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20070422" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomy of the intrinsic hand muscles revisited: part II. Lumbricals" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Eladoumikdachi" 1 => "P.L. Valkov" 2 => "J. Thomas" 3 => "D.T. Netscher" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2002" "volumen" => "110" "paginaInicial" => "1225" "paginaFinal" => "1231" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12360059" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development and morphogenesis of human wrist joint during embryonic and early fetal period" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Hita-Contreras" 1 => "A. Martínez-Amat" 2 => "R. Ortiz" 3 => "O. Caba" 4 => "P. Alvarez" 5 => "J.C. Prados" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1469-7580.2012.01496.x" "Revista" => array:6 [ "tituloSerie" => "J Anat" "fecha" => "2012" "volumen" => "220" "paginaInicial" => "580" "paginaFinal" => "590" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22428933" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomy and function of lumbrical muscles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Palti" 1 => "M. Vigler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hcl.2011.09.002" "Revista" => array:6 [ "tituloSerie" => "Hand Clin" "fecha" => "2012" "volumen" => "28" "paginaInicial" => "13" "paginaFinal" => "17" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22117920" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomic variations in the first extensor compartment of the wrist: accuracy of US" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Rousset" 1 => "V. Vuillemin-Bodaghi" 2 => "J.D. Laredo" 3 => "C. Parlier-Cuau" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.10092265" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2010" "volumen" => "257" "paginaInicial" => "427" "paginaFinal" => "433" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20829530" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MRI features of intersection syndrome of the forearm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.R. Costa" 1 => "W.B. Morrison" 2 => "J.A. Carrino" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2214/ajr.181.5.1811245" "Revista" => array:6 [ "tituloSerie" => "AJR Am J Roentgenol" "fecha" => "2003" "volumen" => "181" "paginaInicial" => "1245" "paginaFinal" => "1249" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14573413" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intersection syndrome: MR imaging with anatomic comparison of the distal forearm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.E. de Lima" 1 => "H.J. Kim" 2 => "F. Albertotti" 3 => "D. Resnick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00256-004-0832-4" "Revista" => array:6 [ "tituloSerie" => "Skeletal Radiol" "fecha" => "2004" "volumen" => "33" "paginaInicial" => "627" "paginaFinal" => "631" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15365785" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound assessment of transverse carpal ligament thickness: a validity and reliability study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Z.L. Shen" 1 => "Z.M. Li" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ultrasmedbio.2012.02.021" "Revista" => array:6 [ "tituloSerie" => "Ultrasound Med Biol" "fecha" => "2012" "volumen" => "38" "paginaInicial" => "982" "paginaFinal" => "988" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22502882" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomical study of the median nerve in the carpal tunnel and etiologies of the carpal-tunnel syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H. Robbins" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Bone Joint Surg Am" "fecha" => "1963" "volumen" => "45" "paginaInicial" => "953" "paginaFinal" => "966" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14047366" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The microvacuolar system: how connective tissue sliding works" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.C. Guimberteau" 1 => "J.P. Delage" 2 => "D.A. McGrouther" 3 => "J.K. Wong" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Hand Surg Eur" "fecha" => "2010" "volumen" => "35" "paginaInicial" => "614" "paginaFinal" => "622" ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0195" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Permeability of the subsynovial connective tissue in the human carpal tunnel: a cadaver study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N. Osamura" 1 => "C. Zhao" 2 => "M.E. Zobitz" 3 => "K.N. An" 4 => "P.C. Amadio" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Biomech" "fecha" => "2007" "volumen" => "22" "paginaInicial" => "524" "paginaFinal" => "528" ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0200" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The anatomy of the distal ulnar tunnel" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.S. Gross" 1 => "R.H. Gelberman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Orthop Relat Res" "fecha" => "1985" "volumen" => "196" "paginaInicial" => "238" "paginaFinal" => "247" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3995823" "web" => "Medline" ] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0205" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomy of the palmar branch of the ulnar nerve: application to ulnar and median nerve decompressive surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.S. Tubbs" 1 => "J.M. Rogers" 2 => "M. Loukas" 3 => "A. Cömert" 4 => "M.M. Shoja" 5 => "A.A. Cohen-Gadol" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/2010.3.JNS091249" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg" "fecha" => "2011" "volumen" => "114" "paginaInicial" => "263" "paginaFinal" => "267" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20367079" "web" => "Medline" ] ] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0210" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Magnetic resonance neurography of median neuropathies proximal to the carpal tunnel" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.K. Thawait" 1 => "T.K. Subhawong" 2 => "S.K. Thawait" 3 => "G. Andreisek" 4 => "A.J. Belzberg" 5 => "J. Eng" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00256-012-1380-y" "Revista" => array:6 [ "tituloSerie" => "Skeletal Radiol" "fecha" => "2012" "volumen" => "41" "paginaInicial" => "623" "paginaFinal" => "632" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22426804" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/1699258X/00000008000000S2/v1_201305061530/S1699258X12002422/v1_201305061530/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/1699258X/00000008000000S2/v1_201305061530/S1699258X12002422/v1_201305061530/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12002422?idApp=UINPBA00004M"]

Estadísticas

Clinical Anatomy of the Hand

Anatomía clínica de la mano

Angélica Vargasa,i,

Autor para correspondencia

vargasgan@yahoo.com

Corresponding author.

, Karla Chiapas-Gascab,i, Cristina Hernández-Díazc,i, Juan J. Canosod,e,i, Miguel Ángel Saavedraf,i, José Eduardo Navarro-Zarzag,i, Pablo Villaseñor-Oviesh,i, Robert A. Kalishe,i

a Rheumatology Department, National Institute of Cardiology, Mexico City, Mexico

b Musculoskeletal Ultrasonography Laboratory Department, National Institute of Rehabilitation, Mexico City, Mexico

c Musculoskeletal Ultrasonography Laboratory Department, National Institute of Rehabilitation, Mexico City, Mexico

d ABC Medical Center, Mexico City, Mexico

e Tufts University School of Medicine, Boston, MA, United States

f Rheumatology Department, La Raza National Medical Center, Mexico City, Mexico

g Hospital General de Chilpancingo Dr. Raymundo Abarca Alarcón, Chilpancingo, Guerrero, Mexico

h Rheumatologist, Tijuana, Mexico

i Mexican Group for the Study of Clinical Anatomy (GMAC), Mexico

Leído

50893

Veces
se ha leído el artículo

11135

Total PDF

39758

Total HTML

Compartir estadísticas

 array:23 [
  "pii" => "S1699258X12002422"
  "issn" => "1699258X"
  "doi" => "10.1016/j.reuma.2012.10.004"
  "estado" => "S300"
  "fechaPublicacion" => "2012-12-01"
  "aid" => "497"
  "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;. All rights reserved"
  "copyrightAnyo" => "2012"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "fla"
  "cita" => "Reumatol Clin. 2012;8 Supl 2:25-32"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 26252
    "formatos" => array:3 [
      "EPUB" => 156
      "HTML" => 21729
      "PDF" => 4367
    ]
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S1699258X12002446"
    "issn" => "1699258X"
    "doi" => "10.1016/j.reuma.2012.10.006"
    "estado" => "S300"
    "fechaPublicacion" => "2012-12-01"
    "aid" => "499"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Reumatol Clin. 2012;8 Supl 2:33-8"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 16235
      "formatos" => array:3 [
        "EPUB" => 172
        "HTML" => 12807
        "PDF" => 3256
      ]
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "titulo" => "Clinical Anatomy of the Pelvis and Hip"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "33"
          "paginaFinal" => "38"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Anatom&#237;a cl&#237;nica de la pelvis y la cadera"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0040"
          "etiqueta" => "Fig&#46; 8"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr8.jpeg"
              "Alto" => 1313
              "Ancho" => 1000
              "Tamanyo" => 116736
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">In this patient &#40;Patient 5&#41; the angio-TAC showed complete occlusion of the right iliac artery&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Jos&#233; Eduardo Navarro-Zarza, Pablo Villase&#241;or-Ovies, Ang&#233;lica Vargas, Juan J&#46; Canoso, Karla Chiapas-Gasca, Cristina Hern&#225;ndez-D&#237;az, Miguel &#193;ngel Saavedra, Robert A&#46; Kalish"
          "autores" => array:8 [
            0 => array:2 [
              "nombre" => "Jos&#233; Eduardo"
              "apellidos" => "Navarro-Zarza"
            ]
            1 => array:2 [
              "nombre" => "Pablo"
              "apellidos" => "Villase&#241;or-Ovies"
            ]
            2 => array:2 [
              "nombre" => "Ang&#233;lica"
              "apellidos" => "Vargas"
            ]
            3 => array:2 [
              "nombre" => "Juan J&#46;"
              "apellidos" => "Canoso"
            ]
            4 => array:2 [
              "nombre" => "Karla"
              "apellidos" => "Chiapas-Gasca"
            ]
            5 => array:2 [
              "nombre" => "Cristina"
              "apellidos" => "Hern&#225;ndez-D&#237;az"
            ]
            6 => array:2 [
              "nombre" => "Miguel &#193;ngel"
              "apellidos" => "Saavedra"
            ]
            7 => array:2 [
              "nombre" => "Robert A&#46;"
              "apellidos" => "Kalish"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12002446?idApp=UINPBA00004M"
    "url" => "/1699258X/00000008000000S2/v1_201305061530/S1699258X12002446/v1_201305061530/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S1699258X12002471"
    "issn" => "1699258X"
    "doi" => "10.1016/j.reuma.2012.10.009"
    "estado" => "S300"
    "fechaPublicacion" => "2012-12-01"
    "aid" => "502"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Reumatol Clin. 2012;8 Supl 2:13-24"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 29983
      "formatos" => array:3 [
        "EPUB" => 170
        "HTML" => 25708
        "PDF" => 4105
      ]
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "titulo" => "Clinical Anatomy of the Elbow and Shoulder"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "13"
          "paginaFinal" => "24"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Anatom&#237;a cl&#237;nica del hombro y el codo"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0040"
          "etiqueta" => "Fig&#46; 8"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "fuente" => "From Gray&#39;s Anatomy 1918 Ed&#46;&#44; Lea and Febiger&#44; Philadelphia&#44; in public domain&#46;"
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr8.jpeg"
              "Alto" => 1649
              "Ancho" => 1490
              "Tamanyo" => 249998
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Lateral view of the scapular components of the glenohumeral joint&#46; The labrum glenoidale &#40;glenoid ligament&#41; in continuity with the tendon of the long head of biceps is shown&#46; The acromion&#44; the coracoacromial ligament and the coracoid process form the coracacromial arch that protects superiorly the glenohumeral joint&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Pablo Villase&#241;or-Ovies, Ang&#233;lica Vargas, Karla Chiapas-Gasca, Juan J&#46; Canoso, Cristina Hern&#225;ndez-D&#237;az, Miguel &#193;ngel Saavedra, Jos&#233; Eduardo Navarro-Zarza, Robert A&#46; Kalish"
          "autores" => array:8 [
            0 => array:2 [
              "nombre" => "Pablo"
              "apellidos" => "Villase&#241;or-Ovies"
            ]
            1 => array:2 [
              "nombre" => "Ang&#233;lica"
              "apellidos" => "Vargas"
            ]
            2 => array:2 [
              "nombre" => "Karla"
              "apellidos" => "Chiapas-Gasca"
            ]
            3 => array:2 [
              "nombre" => "Juan J&#46;"
              "apellidos" => "Canoso"
            ]
            4 => array:2 [
              "nombre" => "Cristina"
              "apellidos" => "Hern&#225;ndez-D&#237;az"
            ]
            5 => array:2 [
              "nombre" => "Miguel &#193;ngel"
              "apellidos" => "Saavedra"
            ]
            6 => array:2 [
              "nombre" => "Jos&#233; Eduardo"
              "apellidos" => "Navarro-Zarza"
            ]
            7 => array:2 [
              "nombre" => "Robert A&#46;"
              "apellidos" => "Kalish"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12002471?idApp=UINPBA00004M"
    "url" => "/1699258X/00000008000000S2/v1_201305061530/S1699258X12002471/v1_201305061530/en/main.assets"
  ]
  "en" => array:18 [
    "idiomaDefecto" => true
    "titulo" => "Clinical Anatomy of the Hand"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "25"
        "paginaFinal" => "32"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Ang&#233;lica Vargas, Karla Chiapas-Gasca, Cristina Hern&#225;ndez-D&#237;az, Juan J&#46; Canoso, Miguel &#193;ngel Saavedra, Jos&#233; Eduardo Navarro-Zarza, Pablo Villase&#241;or-Ovies, Robert A&#46; Kalish"
        "autores" => array:8 [
          0 => array:4 [
            "nombre" => "Ang&#233;lica"
            "apellidos" => "Vargas"
            "email" => array:1 [
              0 => "vargasgan&#64;yahoo&#46;com"
            ]
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">¿</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Karla"
            "apellidos" => "Chiapas-Gasca"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Cristina"
            "apellidos" => "Hern&#225;ndez-D&#237;az"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Juan J&#46;"
            "apellidos" => "Canoso"
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Miguel &#193;ngel"
            "apellidos" => "Saavedra"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Jos&#233; Eduardo"
            "apellidos" => "Navarro-Zarza"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">g</span>"
                "identificador" => "aff0035"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "Pablo"
            "apellidos" => "Villase&#241;or-Ovies"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">h</span>"
                "identificador" => "aff0040"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "Robert A&#46;"
            "apellidos" => "Kalish"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:9 [
          0 => array:3 [
            "entidad" => "Rheumatology Department&#44; National Institute of Cardiology&#44; Mexico City&#44; Mexico"
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Musculoskeletal Ultrasonography Laboratory Department&#44; National Institute of Rehabilitation&#44; Mexico City&#44; Mexico"
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Musculoskeletal Ultrasonography Laboratory Department&#44; National Institute of Rehabilitation&#44; Mexico City&#44; Mexico"
            "etiqueta" => "<span class="elsevierStyleSup">c</span>"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "ABC Medical Center&#44; Mexico City&#44; Mexico"
            "etiqueta" => "<span class="elsevierStyleSup">d</span>"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Tufts University School of Medicine&#44; Boston&#44; MA&#44; United States"
            "etiqueta" => "<span class="elsevierStyleSup">e</span>"
            "identificador" => "aff0025"
          ]
          5 => array:3 [
            "entidad" => "Rheumatology Department&#44; La Raza National Medical Center&#44; Mexico City&#44; Mexico"
            "etiqueta" => "<span class="elsevierStyleSup">f</span>"
            "identificador" => "aff0030"
          ]
          6 => array:3 [
            "entidad" => "Hospital General de Chilpancingo Dr&#46; Raymundo Abarca Alarc&#243;n&#44; Chilpancingo&#44; Guerrero&#44; Mexico"
            "etiqueta" => "<span class="elsevierStyleSup">g</span>"
            "identificador" => "aff0035"
          ]
          7 => array:3 [
            "entidad" => "Rheumatologist&#44; Tijuana&#44; Mexico"
            "etiqueta" => "<span class="elsevierStyleSup">h</span>"
            "identificador" => "aff0040"
          ]
          8 => array:3 [
            "entidad" => "Mexican Group for the Study of Clinical Anatomy &#40;GMAC&#41;&#44; Mexico"
            "etiqueta" => "<span class="elsevierStyleSup">i</span>"
            "identificador" => "aff0045"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Anatom&#237;a cl&#237;nica de la mano"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0045"
        "etiqueta" => "Fig&#46; 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr9.jpeg"
            "Alto" => 609
            "Ancho" => 1174
            "Tamanyo" => 121603
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The dorsal fibrous tunnels are shown&#46; An important landmark is the dorsal tubercle of radius &#40;Lister&#39;s tubercle&#41; which lies radial to extensor pollicis longus &#40;EPL&#41;&#46; This is a frequent site of tendon rupture in rheumatoid arthritis&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;22&#44; with permission&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">General Considerations</span><p id="par0005" class="elsevierStylePara elsevierViewall">The hand is arranged along 5 rays that in full extension spread apart and in full flexion come together without overlaps&#44; except the thumb&#44; and with an admirable surface economy&#46; The basis of this arrangement is a fixed dorsal convexity of the distal carpal row that translates to the metacarpals and from these to the phalanges&#46; In addition&#44; grasp activities depend on a fixed ratio of 1&#58;1&#46;6 for each segment of a digital ray as compared to its proximal fellow&#46; This provides a perfect adaptability of the fingers for all diameters of an object&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> For the fingers 2&#8211;5 passive lateral motions are possible having the hand flat&#46; However&#44; progressive flexion of the MCP causes progressive loss of this motion so that at 90 degrees flexion lateral motions are no longer possible&#46; This is due to the eccentricity of the medial and lateral collateral ligaments of the MCP joint &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In rheumatoid arthritis&#44; chronic inflammation may damage the capsular tissues resulting in an unstable finger at full flexion of the MCP joint&#46; The thumb MCP has no lateral motion in full extension and full flexion but is more than rewarded by the CMC &#40;trapezium-metacarpal&#41; motion that allows a boom-like swing of the metacarpal while preserving the flexion and extension movements of the thumb&#46; Additionally&#44; the thumb CMC exhibits a counter-clockwise rotation &#8211; as looked from proximal to distal &#8211; which makes the alignment of the thumb nail to the finger nails progressively more perfect as the little finger is approached&#46; A disservice to the hand has been to depict it as a flat structure&#44; thumb out&#44; as in the dissection table&#46; In the real state&#44; as we all know&#44; the wrist is slightly dorsiflexed&#44; the MCFs and the IFs slightly flexed&#44; and the 1st web at about 90 degrees to the other web spaces&#46; Strength and precision are attributes of the human hand&#46; Strength is delivered primarily by the long flexors and extensors&#44; but a hand without intrinsic muscles&#44; while maintaining its strength&#44; is only useful as a hook&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The wrist&#44; which is part of the hand&#44; allows the hand to work in extension&#44; in flexion and in ulnar and radial deviation&#46; But the all-important forearm pronation and supination are provided by the distal radioulnar joint&#44; the humeroradial and&#44; to a lesser extent&#44; the humeroulnar joints&#46; The neutral position of the wrist is thumb up&#46; In pronation&#44; or palm down&#44; the distal ulnar head becomes more prominent while the radius&#44; with the triangular ligament attached&#44; has fallen palm down&#46; This makes the extensor carpi ulnaris &#40;ECU&#41; tendon to appear in the ulnarmost portion of the wrist&#46; Once again thumb up&#44; the ECU tendon is felt to overlap dorsally the distal ulnar head&#46; Now in supination&#44; or palm up&#44; the ECU tendon appears between the distal ulnar head and the radius&#46; The cases that follow highlight clinically relevant aspects of the hand that are only rarely discussed during rheumatology training&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patient 1</span>&#46; Trigger finger<span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#8220;A 56 year-old man has a trigger finger&#8221;</p></span></p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patient 2&#46;</span> Trigger thumb<span class="elsevierStyleDisplayedQuote" id="dsq0010"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#8220;A 50 year-old woman has a trigger thumb&#8221;</p></span></p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patient 3</span>&#46; Rheumatoid flexor tenosynovitis<span class="elsevierStyleDisplayedQuote" id="dsq0015"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#8220;A 32 year-old woman with insufficiently treated rheumatoid arthritis has pain and swelling in the left index finger which cannot actively reach the palm&#8221;</p></span></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Relevant Anatomy Amenable to Self and Cross Recognition</span><p id="par0025" class="elsevierStylePara elsevierViewall">Cases 1&#44; 2 and 3 focus our attention on the digital flexor sheaths&#44; which comprise fibrous and synovial structures&#44; and highlight the important role of the palmar creases both in diagnosis and as a guide for corticosteroid injections in flexor tenosynovial conditions&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Palmar Fascia</span><p id="par0030" class="elsevierStylePara elsevierViewall">The palmar fascia is a triangle shaped&#44; tough sheet of connective tissue placed deep to the skin in the palm of the hand &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Ulnarly it is limited by the hypothenar muscles and laterally by the thenar muscles&#46; Skin displacement during grip is prevented by fibrovascular septae with loculated fat in between that link the skin to the palmar fascia&#46; This arrangement resembles closely to the plantar fat pad&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition&#44; seven sagittal ligaments join the palmar fascia to the deep metacarpals fascia and result in 8 tunnels&#44; 4 for the flexor tendons and 4 for the lumbricals<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> distal to the central compartment of the hand&#46; The superficial fibers of the palmar fascia fan out from palmaris longus and continue in the fingers as the pretendinous band&#44; the spiral fibers and the lateral digital sheet&#46; All of these structures&#44; as well as the vertical septae that link the palmar fascia to the skin&#44; are important in the pathogenesis of Dupuytren&#39;s contracture&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> The deep fibers are generally transverse and can be considered an extension of the transverse carpal ligament into the palm&#46; The fascia that covers the thenar and hypothenar muscles&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> in contrast to the thick and complex palmar fascia&#44; is thin and adherent to muscle&#46; There is a superficial&#44; transverse muscle that can be seen to bulge in the hypothenar eminence which originates in the palmar fascia and inserts in the skin&#46; This is palmaris brevis&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The function of this peculiar muscle is conjectural&#46; On the one hand it deepens the cupping of the hand when we drink from it&#46; Also&#44; it contracts synergistically then the 5th MCP is flexed with the PIP and the DIP in extension and during the abduction of the 5th digit&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Digital Flexor Sheaths</span><p id="par0035" class="elsevierStylePara elsevierViewall">Participants will have traced on their hands the full length of the digital flexor sheaths&#46; They should understand the role of the restraining fibrous structures that maintain the tendons in close vicinity to bone and prevent bowstringing during flexion of the digits&#44; the anular and cruciform pulleys&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Although pulleys are discontinuous when the fingers are extended&#44; with synovial tissue in between&#44; they come together and form an almost continuous tube when the fingers are flexed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The A1 pulley&#44; being the most proximal and therefore the one that deflects the flexor tendons is the one that stands the greatest tendon&#47;pulley pressures&#46; Resulting swelling and chondroid changes in both the pulley and the tendon lead to nodule formation and the trigger phenomenon&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Although patients sometimes perceive the entrapment elsewhere the trigger phenomenon is an A1 pulley affair&#46; Because finger flexor muscles are stronger than extensors trigger fingers are usually caught in flexion&#46; A permanent flexor deformity may result in late&#44; unrelieved cases&#46; An additional restraining fibrous structure is the palmar aponeurosis pulley which is comprised of transverse fibers of the palmar fascia&#46; This restraint&#44; which is of marginal importance in normals&#44; helps at preventing bowstringing when the A1 or the A2 pulley is cut&#46; The thumb has 3 anular pulleys and an oblique pulley&#46; The thumb A1 pulley&#44; as in the fingers&#44; overlaps the MCP joint&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The correct diagnosis in our patients is a trigger finger in Patient 1 and a trigger thumb in Patient 2&#46; We would like to add that when the MCP joint ligaments are weakened&#44; as in rheumatoid arthritis&#44; the pull of the A1 pulley on the palmar plate and the base of the proximal phalanx in forceful finger flexion may be such as to cause palmar subluxation of the joint&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Proximal Extension of the Flexor Synovial Sheaths</span><p id="par0040" class="elsevierStylePara elsevierViewall">The proximal extension of the synovial flexor tendon sheaths&#44; which are contained in the digital flexor sheaths&#44; will now be shown &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; It is often surprising that the synovial sheath of the little finger connects with the ulnar bursa&#44; a synovial expansion deep in the palm&#44; in over 70&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> This three-layered structure&#44; which provides a gliding surface between the long and short fingers flexors&#44; as well as a gliding surface deep and superficial to these tendons&#44; extends into the carpal tunnel and for about 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm into the distal forearm&#46; The synovial sheath of the long flexor of the thumb&#44; also known as radial bursa&#44; also traverses the palm and the carpal tunnel and extends into the distal forearm&#46; In contrast&#44; the synovial sheaths of the flexor tendons 2&#8211;4 end in the palmar space just short of the A1 pulley at the neck of the metacarpal bones&#46; In Patient 3 the diagnosis is a rheumatoid flexor tenosynovitis&#46; In this condition the swelling&#44; which is due to both tenosynovial proliferation and effusion&#44; involves the finger and the distal portion of the palm&#46; Rheumatoid tenosynovitis may present few local findings but it must be suspected when a rheumatoid patient cannot actively make a full fist but passively the affected fingers can be painlessly flexed&#46; The swelling tends to be diffuse and distend&#44; as in our patient&#44; the palmar cul-de-sac&#46; Needless to say&#44; these patients greatly improve with a well-placed tenosynovial corticosteroid injection&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Palmar Creases and the A1 Pulley</span><p id="par0045" class="elsevierStylePara elsevierViewall">The great British anatomist Frederick Wood Jones stated that creases are the joints of the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Looking at the palm there are 2 transverse creases&#44; the distal and the proximal &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The distal crease&#44; arising in the ulnar side of the hand bends distally and ends in the 2nd web space&#46; The proximal crease begins with the longitudinal thenar crease in the 1st web space and ends short of the hypothenar eminence&#46; An amazing phenomenon occurs when the straight fingers are bent 90 degrees at the MCP joints&#46; Both the distal and the proximal crease come together in a continuous transverse crease&#46; A cord placed in this crease indicates the proximal edge of the A1 pulley for the fingers 2&#8211;5&#46; Deeper structures overlied by this cord include the flexor tendons&#44; the palmar plates&#44; the deep intermetacarpal ligaments that link neighboring palmar plates&#44; and the MCP joints&#46; Look at this region&#44; known as region V or metacarpophalangeal by hand surgeons&#44; from the palm&#44; the radial side and the dorsum to get an idea of its complexity&#46; More distally in the palmar side there is a crease where the finger appears to arise&#44; the proximal digital crease&#46; However&#44; a cord placed around the finger at this crease&#44; looked from the dorsum&#44; crosses the mid portion of the proximal phalanx&#46; Finally&#44; a cord placed around the mid and the distal digital creases roughly overlaps the PIP and the DIP joints&#44; respectively&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Palmar Plates and the Deep Intermetacarpal Ligament</span><p id="par0050" class="elsevierStylePara elsevierViewall">The palmar plates are thick and dense plates &#8211; whether they are fibrocartilaginous or not is in debate &#8211; that reinforce the volar aspect of the MCP joints &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; While distally the palmar plates are firmly attached to the proximal phalanx&#44; proximally they become a thin&#44; membranous capsule&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> Each palmar plate is connected to the neighboring palmar plates by the deep intermetacarpal ligament&#46; Also&#44; sagittal bands &#40;SB&#41; connect the extensor tendon to the edges of the palmar plates&#44; which also give insertion to the accessory MCP lateral collateral ligament and the A1 pulley&#46; Thus&#44; the palmar plates provide a true anchoring system to the fibrous skeleton of the MCP region&#46; Together&#44; the SBs and the palmar plate form a closed cylindrical tube that surrounds the metacarpal head&#46; It is considered that the SBs represent the main stabilizer of the extensor tendon at the MCP joint&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Damage of the radial sagittal fibers is one of the factors leading to ulnar deviation in rheumatoid arthritis&#46; Palmar plates with a similar phalangeal attachment are also present in the interphalangeal joints&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Corticosteroid Infiltration in Trigger Finger&#47;Thumb and Tenosynovitis</span><p id="par0055" class="elsevierStylePara elsevierViewall">In Patient 1 the injecting needle is placed just distal to the proximal transverse crease for the index&#44; between the proximal and distal creases for the middle finger and just distal to the distal crease for the anular and the little finger&#46; There is no need to place the steroid within the synovial sheath in this condition&#46; Indeed&#44; extrasynovial injections appear to work better&#46; The injection for the trigger thumb is quite different and the thumb sesamoids are used as a landmark&#46; The thumb has 2 sesamoid bones which are easily palpable at the base of the thumb on the flexor side&#46; These tiny bones transmit force from the abductor pollicis and the flexor pollicis brevis to the proximal phalanx via the volar plate&#46; They also guide the flexor pollicis longus tendon that lies between them&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The thumb sesamoids vary in size among people and one may be larger than the other&#46; The sesamoids area is normally tender to palpation&#46; The injecting needle is aimed at the sesamoids &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; In Patient 3&#44; with a diagnosis of rheumatoid flexor tenosynovitis&#44; it is quite important to place the steroid within the sheath because synovial tissue is interspersed between pulleys and at both ends of the tube&#46; An intrasynovial injection is felt by the patient as fluid extending distally along the palmar aspect of the finger&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Practical Review of Some Palmar Structures</span><p id="par0060" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Palmar creases</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Dorsal projection of proximal digital crease</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Palmaris brevis muscle</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Palmar fascia and its longitudinal and transverse components &#40;superficial transverse metacarpal ligament&#44; longitudinal and transverse fascicles&#41;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Digital pulleys</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Flexor synovial sheaths</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Flexor tendons</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Palmar plates&#44; approximate position</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Thumb sesamoids</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Tendons that are contained in the carpal tunnel</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patient 4&#46;</span> Interosseous muscle function<span class="elsevierStyleDisplayedQuote" id="dsq0020"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">&#8220;A fellow is asked during the certifying examination&#58; Which muscles separate the fingers and which muscles bring them together&#63; He pales and looks at the examiner in disbelief&#8221;&#46;</p></span></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Relevant Anatomy Amenable to Self and Cross Recognition</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Extensor Lamina</span><p id="par0120" class="elsevierStylePara elsevierViewall">If we overstretch the fingers the extensor tendons&#44; prominent in the dorsum of the hand&#44; are seen to disappear at the fingers&#46; One of the reasons of this phenomenon is that the extensor tendon itself is anchored by sagittal fibers to the palmar cartilaginous plate that reinforces the MCP on the palmar side&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> A second reason is that the extensor tendon becomes embedded in the dorsal digital expansion&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;25</span></a> The dorsal digital expansion may be viewed as an isosceles triangle applied on the proximal phalanx &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; The expansion incorporates the central tendon fibers destined to the base of the middle phalanx&#46; In addition&#44; it contains two previously separated extensor tendon contingents&#44; the radial and the ulnar lateral bands&#44; that join together prior to their destination at the base of the distal phalanx&#46; Also&#44; the interossei muscles as well as the lumbricals&#44; past the deep transverse metacarpal ligament that separates them&#44; run toward the angles of the extensor lamina and once incorporated to this structure&#44; extend along the lateral sides in the middle and lateral conjoined tendons&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In finger flexion the lateral bands slide palmarly over the PIP joint while in extension the tendon pull brings them closer together as to better extend the DIP joint&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Is it possible to palpate the extensor lamina&#63; Yes&#44; by 2-finger palpation&#44; one radial and one ulnar&#44; on the dorsolateral aspect of the proximal phalanx during flexion-extension movements&#46; Is it important&#63; Yes&#44; to get a dynamic idea of what it is going on&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Dorsal Interosseus Muscles</span><p id="par0125" class="elsevierStylePara elsevierViewall">The interosseal muscles&#44; both the dorsal and the palmar &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#44; have their origin in the metacarpals and insert at the corners of the extensor lamina&#46; In addition&#44; the dorsal interossei have a point of insertion in the proximal phalanx&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> Both sets of muscles run dorsal to de deep intermetacarpal ligament&#46; The longitudinal axis of the hand is comprised of the long finger and the 3rd metacarpal&#46; Proof of this is that the 3erd digit stays still when the fingers are spread apart and when they are brought back together&#46; While the dorsal interosseus tendons are so placed as to separate the index and the anular away from the long finger&#44; by having 2 dorsal interossei this finger is able to separate from its own axis to the ulnar and the radial sides&#46; The separation of the little finger is achieved primarily by the abductor digiti minimi and the separation of the thumb primarily by the abductor pollicis brevis&#46; Are the bellies of the dorsal interossei identifiable on examination&#63; The answer is a timid yes for the interossei of the long and anular fingers &#40;you can feel them hardening during abduction with a finger appropriately placed on the dorsum of the hand&#41; and a rotund yes for the index dorsal interosseus&#46; This muscle is eminently placed&#44; as well as distinctly developed in normal subjects&#44; as to allow its clinical identification and functional characterization far beyond dissection&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> An experiment can be made &#8220;in vivo&#8221; by looking at the radial side of the 2nd MCP joint which is free of an overlapping finger&#46; With the tip of a ballpen is possible to identify a point that remains still during flexion-extension movements&#46; This is the transverse axis of the MCP joint&#46; Now let&#39;s abduct the index&#46; This motion brings up a strong muscle belly in the web space&#44; which is no other than the dorsal interosseus muscle&#46; If the free edge of this muscle is followed toward the index a tiny tendon appears to attach to the proximal phalanx &#40;in most cases the attachment is to both bone and the dorsal lamina&#41; about 1<span class="elsevierStyleHsp" style=""></span>cm palmar to the axis point which explains its flexor action on the MCP joint&#46; Furthermore&#44; through the dorsal lamina the same contraction extend the interphalangeal joints&#46; Variations are common in the dorsal interossei&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> All dorsal interossei are innervated by the ulnar nerve&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Palmar Interosseus Muscles</span><p id="par0130" class="elsevierStylePara elsevierViewall">There are 3 palmar interosseous muscles &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#44; one for the index&#44; one for the anular and 1 for the little finger&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> These muscles&#44; similar to the dorsal counterparts&#44; insert near the corner of the dorsal lamina&#44; on the opposite side&#46; With their origins and insertions facing the long finger it is easy to appreciate that they function as adductors&#44; i&#46;e&#46; they bring the fingers close together&#46; Their actions on the transverse axis of the joints are the same as in the dorsal interossei&#44; flexion of the MCP joint and extension of the PIP and DIP joints&#46; The palmar interossei cannot be reliably identified by palpation&#46; Anatomical variations in these muscles are common&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> All palmar interossei are innervated by the ulnar nerve&#46; Before leaving the interosseous muscles let&#39;s make one more experiment&#46; Please note that adduction and abduction of the fingers have been tested in extension&#46; How about with the MCP joints flexed 90 degrees&#63; These motions are not possible&#46; Is this due to the characteristics of insertion of the interosseal muscles&#63; The answer is not&#44; as passive motion is also canceled&#46; The reason for the inability to abduct and adduct the fingers is the eccentric nature of the collateral ligaments of the MCP joints&#46; They are lax in extension and taut in flexion&#46; In rheumatoid arthritis&#44; where damage to the MCP collateral ligaments may occur&#44; lateral finger motion at 90 degrees of MCP flexion is a reliable indicator of this lesion&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Lumbrical Muscles</span><p id="par0135" class="elsevierStylePara elsevierViewall">These unique muscles that really look like earthworms have their origin in the deep flexor tendons in the palm of the hand &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> In their way to the extensor lamina they run palmar to the deep metacarpal ligament&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> A unique characteristic of the lumbrical muscles is that&#44; having had an origin in a flexor muscle their insertion is in the extensor lamina and therefore their main action is to flex the MCP joints while extending the PIP and DIP joints&#46; This flexor&#47;extensor linkage&#44; an abundance of mechanoreceptors&#44; plus a common innervation with the flexor digitorum profundus &#40;index and middle finger&#44; median nerve&#59; ring and small finger&#44; ulnar nerve&#41; is telling us something in a language we still do not understand&#46; Variations in the lumbrical muscles are frequent&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> One such variation that may cause a carpal tunnel syndrome is an origin within the carpal tunnel&#46; An origin in the forearm has also been described&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patient 5</span>&#46; De Quervain&#39;s tenosynovitis&#46;<span class="elsevierStyleDisplayedQuote" id="dsq0025"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#8220;A 79-year old violist presents with severe pain in the radial side of his wrist&#46; He is due to play in a concert in 2 days&#46; On physical examination there is a bulky trapeziometacarpal osteoarthritis&#46; He has a markedly positive Finkelstein test&#46; What am I supposed to do&#63; This patient exemplifies a common clinical situation&#46; When there are concurrent conditions&#44; which one is causing the pain&#63; One of his conditions is known to be rather refractory to treatment&#44; the osteoarthritis&#46; The other&#44; de Quervain&#39;s tenosynovitis&#44; is eminently treatable by a steroid infiltration&#46; This dilemma was presented to the patient and he had no doubts about the correct course of action which was to have the 1st dorsal compartment tenosynovial sheath injected&#46; The infiltration was successful and he was able to play at his concert&#8221;&#46;</p></span></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Relevant Anatomy Amenable to Self and Cross Recognition</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The Extensor Retinaculum and the Dorsal Tendon Compartments</span><p id="par0145" class="elsevierStylePara elsevierViewall">Continuing with our cord experiments&#44; if we place a cord at the distal wrist crease&#44; on the palmar side the cord indicates the proximal limit of the transverse palmar ligament and on the dorsum&#44; the distal limit of the extensor retinaculum &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#41;&#46; Thus&#44; the extensor retinaculum is a forearm extensor tendon restraint and the transverse carpal ligament is a wrist flexor tendon restraint&#46; This concept is critical to an understanding of the contents of the radial-most tendon compartments&#58;first dorsal compartment&#44; abductor pollicis longus &#40;APL&#41; and extensor pollicis brevis &#40;EPB&#41;&#59; second compartment&#44; extensor carpi radialis longus &#40;ECRL&#41; and extensor carpi radialis brevis &#40;ECRB&#41;&#59; and third compartment&#44; extensor pollicis longus &#40;EPL&#41;&#46; Moving distally&#44; at the wrist the first compartment tendons remain the same&#44; but they are followed by EPL and then ECRL and ECRB&#46; The reason for this transposition is an oblique course of EPL at the wrist&#46; Going back to the extensor retinaculum&#44; EPL is flanked radially by a bony eminence&#44; the dorsal tubercle of radius or Lister&#39;s tubercle&#44; that redirects its course&#46; The fourth compartment contains extensor indicis &#40;EI&#41; and extendor digitorum &#40;ED&#41;&#46; The fifth compartment&#44; which is easy to locate between the distal end of ulna and the radius contains extensor digiti minimi &#40;EDM&#41; and the sixth and compartment&#44; extensor carpi ulnaris&#46; At the first compartment both APL and EPB may have multiple slips In addition&#44; a septum and a bone ridge may be present in 30&#37;&#8211;40&#37; between the APL and the EPB tendons&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><elsevierMultimedia ident="fig0045"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Forearm Intersection Syndrome</span><p id="par0150" class="elsevierStylePara elsevierViewall">A unique pain syndrome may occur after heavy labor&#44; the intersection syndrome of the forearm&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> Pain&#44; tenderness and swelling occur dorso-radially in the forearm about 4 FB proximal to Lister&#39;s tubercle&#46; A diagnostic sign is a tendon friction rub brought about by thumb abduction and flexion-extension movements of the wrist&#46; A simple maneuver reveals the anatomy of this condition&#46; Place 4 fingers on the wrist and distal forearm&#44; the little finger next to the base of the 2nd and 3rd metacarpals&#44; the anular over Lister&#39;s tubercle&#44; and the long finger and the index proximal to the latter&#46; Now ask the patient to gently dorsiflex the wrist&#46; The tension of the ECRL and ECRB will be felt with the little finger and less with the other fingers&#46; Let&#39;s now ask the patient to abduct the thumb&#46; The APL and EPB will be tense up and this will be felt by the index but not by the other digits&#46; Indeed&#44; if one runs the index proximally over the radius these muscles will be felt to run obliquely over a generally longitudinal background&#46; To summarize&#44; APL and EPB cross superficially over ECRL and ECRL A rheumatologist with an interest in clinical anatomy should be able to make an instant diagnosis of intersection syndrome&#46; Someone less informed may require an MRI or an ultrasonography study&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Practical Review of Some Dorsal Structures</span><p id="par0155" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Palpation of the extensor lamina</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Palpation of dorsal interossei</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Action of dorsal interossei</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Action of palmar interossei</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Why interossei flex the MCP &#40;review of the insertion of the 1st dorsal interosseus muscle&#41;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Lumbricals action</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Palpatory recognition of trapezium&#44; scaphoid&#44; head of capitate&#44; radial styloid&#44; distal radius&#44; Lister&#39;s tubercle &#40;dorsal radial tubercle&#41;&#44; distal ulna&#44; ulnar styloid</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Visual and palpatory recognition of tendons at the dorsal wrist&#46; From radial to ulnar&#58;abductor pollicis longus &#40;APL&#41;&#44; extensor pollicis brevis &#40;APB&#41;&#44; extensor pollicis longus &#40;EPL&#41;&#44; extensor carpi radialis longus &#40;ECRL&#41;&#44; extensor carpi radialis brevis &#40;ECRB&#41;&#44; extensor indicis &#40;EI&#41;&#44; extensor digitorum &#40;ED&#41;&#44; extensor digiti minimi &#40;EDM&#41;&#44; and extensor carpi ulnaris &#40;ECU&#41;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Anatomical snuffbox &#40;APL&#44; EPB&#44; radial styloid&#44; radius&#44; Lister&#39;s tubercle&#44; scaphoid&#44; trapezium&#44; radial artery&#44; EPL&#41;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Distal boundary of extensor retinaculum</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Intersection site&#44; recognition by palpation of APL and EPB&#44; ECRL and ECRB</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Finkelstein&#39;s maneuver</p></li></ul></p><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patient 6</span>&#46; Carpal tunnel syndrome&#46;<span class="elsevierStyleDisplayedQuote" id="dsq0030"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">&#8220;A 46 year-old woman with rheumatoid arthritis&#46; She has tingling in her hands&#44; decreased pin prick sensation in her thumb and index and early atrophy of abductor pollicis brevis&#8221;</p></span></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Relevant Anatomy Amenable to Self and Cross Recognition</span><p id="par0225" class="elsevierStylePara elsevierViewall">Transverse carpal ligament&#46; This ligament&#44; also known as flexor retinaculum&#44; binds anteriorly the carpal tunnel &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4 and 10</a>&#41;&#46; Its main insertions&#44; on the radial side&#44; are the tubercle of scaphoid and the crest of the trapezium&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> The ulnar side insertions include the pisiform and the hook of hamate&#46; The latter lies deep and can be distinguished only in thin people with supple hands&#46; As mentioned&#44; a string placed at the distal anterior wrist crease indicates the proximal border of the transverse carpal ligament&#46; Nine tendons are contained within the carpal tunnel&#58; four flexor digitorum superficialis tendons&#44; four flexor digitorum profundus tendons and flexor pollicis longus tendon&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Within the tunnel the 3 synovial tongues that make up the ulnar bursa separate the anterior carpal ligament from the superficial flexor tendons&#44; the superficial from the deep flexor tendons&#44; and the deep flexor tendons from the carpal ligaments and bones&#46; On the radial side the synovial sheath of flexor pollicis longus&#44; known as radial bursa&#44; partially surrounds this tendon on its radial&#44; anterior and posterior sides&#46; The median nerve was left to last because it lies superficially in the boundary between the radial and the ulnar bursae&#46; The subsynovial tissue&#44; as in other connective tissues that glide upon each other&#44; has a complex microstructural arrangement&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> In addition&#44; it may act as a barrier to diffusion&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The flexor tendons and the median nerve cannot be palpated while in the carpal tunnel&#46; Tissues are just too tightly packed&#44; the anterior carpal ligament is thick and the inserting thenar and hypothenas muscles almost reach each other anterior to the ligament&#46; The distal edge of the transverse carpal ligament cannot be felt as it blends imperceptively with the palmar fascia&#46;</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">Guyon&#39;s canal&#46; Guyon&#39;s canal is placed anteriorly in the ulnar third of the wrist&#46; This canal has a proximal opening for the ulnar nerve and artery and 2 distal openings&#44; one for the deep &#40;motor&#41; branch of the ulnar nerve and its artery and another for the superficial &#40;sensory&#41; branch of the ulnar nerve and its artery&#46; Gross and Gelberman have recognized 3 distinct zones in this region&#44; zone 1 in which the nerve is still undivided&#44; zone 2 that refers to the opening for the motor branch&#44; and zone 3 that relates to the superficial branch&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The roof of Guyon&#39;s canal includes the palmar carpal ligament in zone 1&#44; palmaris brevis muscle in zone 2 and fat and fibrous tissue in zone 3&#46; An important point in surface innervation is that the radial half of the palm is supplied by the palmar cutaneous branch of the median nerve and its ulnar half&#44; by the palmar cutaneous branch of the ulnar nerve&#46; Both of these branches arise from the corresponding nerves in the distal forearm and being anterior to the transverse ligamentous structures they are not compressed in the carpal tunnel syndrome and the Guyon&#39;s canal syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Tendon boundaries of the median nerve at the distal forearm&#46; As mentioned&#44; the median nerve runs deep into&#44; and in between&#44; palmaris longus and flexor carpi radialis&#46; The ulnar bursa&#44; covering the flexor tendons&#44; extends 2&#8211;2&#46;5<span class="elsevierStyleHsp" style=""></span>cm proximal to the transverse carpal ligament&#46; This synovial extension allows the injection of the largest synovial structure within the carpal tunnel proximal to the tight limits of the tunnel&#46; The radial bursa&#44; which underlies flexor carpi radialis&#44; is a much smaller than the ulnar bursa&#46; It makes sense to inject the larger rather than the smaller synovial structure hoping that volume reduction after the corticosteroid injection would be greater&#46; We use a needle entry medial to palmaris longus&#44; 1&#46;5&#8211;2<span class="elsevierStyleHsp" style=""></span>cm proximal to the distal flexor crease&#44; with a distal angulation of 45 degrees &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11</a>&#41;&#46; Free flow of the local anesthetic without creating a collection indicates a correct placement&#46; Of course&#44; the median nerve and an important branch&#44; the anterior interosseal nerve&#44; as well as the ulnar nerve counterparts&#44; may be compressed more proximally in the forearm&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a></p><elsevierMultimedia ident="fig0055"></elsevierMultimedia></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Practical Review of the Carpal Tunnel and Related Anatomical Structures</span><p id="par0240" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Thumb movements in the functional position of the hand</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Thenar eminence muscles</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Median nerve</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Hypothenar eminence</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Palmar cutaneous muscle&#44; why is it there and how to demonstrate it</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Guyon&#39;s canal</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Transverse carpal ligament and its insertions</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Flexor carpi radialis longus</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Palmaris muscle</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Flexor carpi radialis</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Ulnar bursa &#40;in the palm&#44; the carpal tunnel and the distal forearm&#41;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Tinel&#39;s and Phalen&#39;s maneuvers</p></li></ul></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0305" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:14 [
        0 => array:2 [
          "identificador" => "xres124088"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec111370"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres124089"
          "titulo" => "Resumen"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec111371"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "General Considerations"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Relevant Anatomy Amenable to Self and Cross Recognition"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Palmar Fascia"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Digital Flexor Sheaths"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Proximal Extension of the Flexor Synovial Sheaths"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Palmar Creases and the A1 Pulley"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "The Palmar Plates and the Deep Intermetacarpal Ligament"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Corticosteroid Infiltration in Trigger Finger&#47;Thumb and Tenosynovitis"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Practical Review of Some Palmar Structures"
        ]
        7 => array:3 [
          "identificador" => "sec0050"
          "titulo" => "Relevant Anatomy Amenable to Self and Cross Recognition"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "The Extensor Lamina"
            ]
            1 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "The Dorsal Interosseus Muscles"
            ]
            2 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "The Palmar Interosseus Muscles"
            ]
            3 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "The Lumbrical Muscles"
            ]
          ]
        ]
        8 => array:3 [
          "identificador" => "sec0075"
          "titulo" => "Relevant Anatomy Amenable to Self and Cross Recognition"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "The Extensor Retinaculum and the Dorsal Tendon Compartments"
            ]
            1 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Forearm Intersection Syndrome"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0090"
          "titulo" => "Practical Review of Some Dorsal Structures"
        ]
        10 => array:2 [
          "identificador" => "sec0095"
          "titulo" => "Relevant Anatomy Amenable to Self and Cross Recognition"
        ]
        11 => array:2 [
          "identificador" => "sec0100"
          "titulo" => "Practical Review of the Carpal Tunnel and Related Anatomical Structures"
        ]
        12 => array:2 [
          "identificador" => "sec0105"
          "titulo" => "Conflict of Interest"
        ]
        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2012-10-04"
    "fechaAceptado" => "2012-10-24"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec111370"
          "palabras" => array:8 [
            0 => "Hand"
            1 => "Trigger finger"
            2 => "Trigger thumb"
            3 => "Rheumatoid flexor tenosynovitis"
            4 => "Interosseus muscles"
            5 => "Lumbrical muscles"
            6 => "De Quervain&#39;s tenosynovitis"
            7 => "Carpal tunnel syndrome"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec111371"
          "palabras" => array:8 [
            0 => "Mano"
            1 => "Dedo en gatillo"
            2 => "Pulgar en gatillo"
            3 => "Tenosinovitis flexora reumatoidea"
            4 => "M&#250;sculos inter&#243;seos"
            5 => "M&#250;sculos lumbricales"
            6 => "Tenosinovitis de De Quervain"
            7 => "S&#237;ndrome del tunel del carpo"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This article reviews the underlying anatomy of trigger finger and thumb &#40;fibrous digital pulleys&#44; sesamoid bones&#41;&#44; flexor tenosynovitis&#44; de Quervain&#39;s syndrome&#44; Dupuytren&#39;s contracture&#44; some hand deformities in rheumatoid arthritis&#44; the carpal tunnel syndrome and the ulnar nerve compression at Guyon&#39;s canal&#46; Some important syndromes and structures have not been included but such are the nature of these seminars&#46; Rather than being complete&#44; we aim at creating a system in which clinical cases are used to highlight the pertinent anatomy and&#44; in the most important part of the seminar&#44; these pertinent items are demonstrated by cross examination of participants and teachers&#46; Self learning is critical for generating interest and expanding knowledge of clinical anatomy&#46; Just look at your own hand in various positions&#44; move it&#44; feel it&#44; feel also your forearms while you move the fingers&#44; do this repeatedly and inquisitively and after a few tries you will have developed not only a taste&#44; but also a lifelong interest in clinical anatomy&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En este art&#237;culo revisa la anatom&#237;a subyacente en el dedo en gatillo y el pulgar en gatillo &#40;poleas digitales fibrosas&#44; huesos sesamoideos&#41;&#44; tenosinovitis flexora&#44; s&#237;ndrome de De Quervain&#44; contractura de Dupuytren&#44; algunas deformidades de la mano en la artritis reumatoide&#44; el s&#237;ndrome del t&#250;nel carpiano y la compresi&#243;n del nervio cubital en el canal de Guyon&#46; Debido a la naturaleza de estos seminarios&#44; no se han incluido algunos s&#237;ndromes importantes y estructuras&#46; M&#225;s que ser exhaustivos&#44; nuestro objetivo es crear un sistema en el que los casos cl&#237;nicos se utilizan para resaltar la anatom&#237;a pertinente y&#44; en la parte m&#225;s importante del seminario&#44; estos elementos se muestran a partir de una examen cruzado entre participantes y profesores&#46; El autoaprendizaje es fundamental para generar inter&#233;s y ampliar el conocimiento de la anatom&#237;a cl&#237;nica&#46; Basta con mirarse las propias manos en distintas posturas&#44; moverlas&#44; sentirlas&#59; sientan tambi&#233;n el antebrazo mientras mueven los dedos&#44; h&#225;ganlo varias veces&#44; con espiritu de indagaci&#243;n&#44; y tras unos pocos intentos no solo habr&#225;n adquirido un gusto&#44; sino un inter&#233;s por la anatom&#237;a cl&#237;nica&#46;</p>"
      ]
    ]
    "multimedia" => array:11 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1318
            "Ancho" => 1275
            "Tamanyo" => 121909
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Upper panel&#46; MCP joint showing the metacarpophalangeal joint &#40;MCP&#41; in neutral&#46; The collateral ligament is relaxed&#46; Note tibrocartilaginous palmar plate in the palmar aspect of the joint&#46; Lower panel&#46; The lateral collateral ligament becomes taut in flexion&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;16&#44; with permission&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2492
            "Ancho" => 1544
            "Tamanyo" => 413958
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; The palmar fascia&#46; The longitudinal fibers derive from palmaris longus tendon&#46; Note the transverse fibers of palmaris brevis&#44; a subcutaneous musle at the hypothenar eminence&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;16&#44; with permission&#46; &#40;b&#41; A transverse section of the hand&#46; The palmar fascia is located near the palmar surface&#46; It is connected to the dermis by fibrous strands that loculate tiny fat lobules&#46; Septae connect the deep aspect of the palmar fascia to the deep fascia that overlies the metacarpals and the interosseous muscles &#40;the insert shows the site of the section&#41;&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;16&#44; with permission&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1080
            "Ancho" => 1048
            "Tamanyo" => 89570
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">This is a simplified rendition of the fibrous digital pulleys&#46; The proximal pulley&#44; A1&#44; inserts in the palmar plate and in the transverse metacarpal ligament that binds neighboring palmar plates&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;22&#44; with permission&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1197
            "Ancho" => 808
            "Tamanyo" => 171511
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">This figure shows the relationship between the transverse palmar creases and the flexor synovial sheaths&#46; Note that for the digits 2&#44;3&#44;4 the synovial sheaths end near the transverse creases&#46; For the thumb and the small finger the sheaths extend to the distal forearm&#46; The expansion of the latter in the mid palm is the ulnar bursa&#44; a synovial structure extends to the carpal tunnel and the distal forearm&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;24&#44; with permission&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Fig&#46; 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 530
            "Ancho" => 750
            "Tamanyo" => 72800
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">In the trigger thumb the needle is inserted toward the sesamoid bones&#44; which coincide with the proximal anular pulley of the thumb&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Fig&#46; 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 731
            "Ancho" => 1361
            "Tamanyo" => 123464
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The extensor lamina is a triangular fibrous sheath in the dorsum of the proximal phalanx&#46; The extensor tendon is incorporated into this lamina and the interosseous muscles and the lumbrical muscles attach to its sides&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;54&#44; with permission&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Fig&#46; 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 777
            "Ancho" => 1672
            "Tamanyo" => 175857
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The left panel depicts the palmar interosseus muscles&#46; These are three and given their disposition they bring the index&#44; the anular and the little finger toward the 3rd finger which is the axis of the hand&#46; The dorsal interosseus muscles are shown in the right panel&#46; The middle finger has two and the anular and the index fingers have one&#46; Their disposition is such that they separate the fingers from the 3rd finger&#44; and move the 3rd finger to one and the other side&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;20&#44; with permission&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Fig&#46; 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 922
            "Ancho" => 1249
            "Tamanyo" => 117279
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The lumbrical muscles are shown&#46; They are palmar&#44; while the dorsal and the palmar interossei are dorsal&#44; to the transverse metacarpal ligament&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;20&#44; with permission&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "fig0045"
        "etiqueta" => "Fig&#46; 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr9.jpeg"
            "Alto" => 609
            "Ancho" => 1174
            "Tamanyo" => 121603
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The dorsal fibrous tunnels are shown&#46; An important landmark is the dorsal tubercle of radius &#40;Lister&#39;s tubercle&#41; which lies radial to extensor pollicis longus &#40;EPL&#41;&#46; This is a frequent site of tendon rupture in rheumatoid arthritis&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;22&#44; with permission&#46;</p>"
        ]
      ]
      9 => array:7 [
        "identificador" => "fig0050"
        "etiqueta" => "Fig&#46; 10"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr10.jpeg"
            "Alto" => 712
            "Ancho" => 1230
            "Tamanyo" => 69479
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">This sketch depicts the four main osseous insertions of the transverse carpal ligament&#46; This ligament binds anteriorly the carpal tunnel&#46; From A Companion to Medical Studies&#44; Volume 1&#44; Ed&#46; by Passmore R and Robson JS&#44; 2nd Edition&#44; Oxford&#44; Wiley&#47;Blackwell 1976&#44; p&#46; 23&#46;22&#44; with permission&#46;</p>"
        ]
      ]
      10 => array:7 [
        "identificador" => "fig0055"
        "etiqueta" => "Fig&#46; 11"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr11.jpeg"
            "Alto" => 563
            "Ancho" => 750
            "Tamanyo" => 97719
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">One of the techniques of infiltration in carpal tunnel syndrome is shown&#46; The needle is inserted ulnar to the palmaris longus tendon 1&#46;5&#8211;2<span class="elsevierStyleHsp" style=""></span>cm proximal to the distal flexor crease of the wrist&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:42 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "On the adaptability of man&#39;s hand &#40;with reference to the equiangular curve&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;W&#46; Littler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Hand"
                        "fecha" => "1973"
                        "volumen" => "5"
                        "paginaInicial" => "187"
                        "paginaFinal" => "191"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4583856"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The reconstruction of the hand in leprosy&#46; Hunterian Lecture delivered at the Royal College of Surgeons of England"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P&#46;W&#46; Brand"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann R Coll Surg Engl"
                        "fecha" => "1952"
                        "volumen" => "11"
                        "paginaInicial" => "350"
                        "paginaFinal" => "361"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12996957"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The fascia of the limbs and back&#8212;a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46; Benjamin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1469-7580.2008.01011.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Anat"
                        "fecha" => "2009"
                        "volumen" => "214"
                        "paginaInicial" => "1"
                        "paginaFinal" => "18"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19166469"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Three-dimensional morphology of heel fat pad&#58; an in vivo computed tomography study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "V&#46; Campanelli"
                            1 => "M&#46; Fantini"
                            2 => "N&#46; Faccioli"
                            3 => "A&#46; Cangemi"
                            4 => "A&#46; Pozzo"
                            5 => "A&#46; Sbarbati"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1469-7580.2011.01420.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Anat"
                        "fecha" => "2011"
                        "volumen" => "219"
                        "paginaInicial" => "622"
                        "paginaFinal" => "631"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21848602"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The palmar aponeurosis and the central spaces of the hand"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "F&#46; Bojsen-M&#248;ller"
                            1 => "L&#46; Schmidt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Anat"
                        "fecha" => "1974"
                        "volumen" => "117"
                        "paginaInicial" => "55"
                        "paginaFinal" => "68"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4844651"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dupuytren&#39;s contracture unfolded"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "W&#46;A&#46; Townley"
                            1 => "R&#46; Baker"
                            2 => "N&#46; Sheppard"
                            3 => "A&#46;O&#46; Grobbelaar"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.332.7538.397"
                      "Revista" => array:6 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2006"
                        "volumen" => "332"
                        "paginaInicial" => "397"
                        "paginaFinal" => "400"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16484265"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scientific understanding and clinical management of Dupuytren disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "B&#46; Shih"
                            1 => "A&#46; Bayat"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/nrrheum.2010.180"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nat Rev Rheumatol"
                        "fecha" => "2010"
                        "volumen" => "6"
                        "paginaInicial" => "715"
                        "paginaFinal" => "726"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21060335"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomy and function of the thenar muscles"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46; Gupta"
                            1 => "H&#46; Michelsen-Jost"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.hcl.2011.09.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hand Clin"
                        "fecha" => "2012"
                        "volumen" => "28"
                        "paginaInicial" => "1"
                        "paginaFinal" => "7"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22117918"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomy and function of the hypothenar muscles"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;A&#46; Pasquella"
                            1 => "P&#46; Levine"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.hcl.2011.09.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hand Clin"
                        "fecha" => "2012"
                        "volumen" => "28"
                        "paginaInicial" => "19"
                        "paginaFinal" => "25"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22117921"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The palmaris brevis&#8212;a reconsideration of its anatomy and possible function"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;M&#46; Shrewsbury"
                            1 => "R&#46;K&#46; Johnson"
                            2 => "D&#46;K&#46; Ousterhout"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Bone Joint Surg Am"
                        "fecha" => "1972"
                        "volumen" => "54"
                        "paginaInicial" => "344"
                        "paginaFinal" => "348"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4651265"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Palmar and digital flexor tendon pulleys"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;R&#46; Doyle"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Orthop Rel Res"
                        "fecha" => "2001"
                        "volumen" => "383"
                        "paginaInicial" => "84"
                        "paginaFinal" => "96"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Trigger finger and tendinosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;C&#46; Lundin"
                            1 => "P&#46; Eliasson"
                            2 => "P&#46; Aspenberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Hand Surg Eur"
                        "fecha" => "2012"
                        "volumen" => "37"
                        "paginaInicial" => "233"
                        "paginaFinal" => "236"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The pulley system of the thumb&#58; anatomic and biomechanical study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Bayat"
                            1 => "H&#46; Shaaban"
                            2 => "G&#46; Giakas"
                            3 => "V&#46;C&#46; Lees"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hand Surg Am"
                        "fecha" => "2002"
                        "volumen" => "27"
                        "paginaInicial" => "628"
                        "paginaFinal" => "635"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12132087"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tendon sheath patterns in the hand&#58; an anatomical study based on 367 hand dissections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "E&#46;W&#46; Scheldrup"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Surg Gynecol Obstet"
                        "fecha" => "1951"
                        "volumen" => "93"
                        "paginaInicial" => "16"
                        "paginaFinal" => "22"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14855245"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The Principles of Anatomy as Seen in the Hand"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "F&#46; Wood Jones"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "1949"
                        "editorial" => "Bailli&#232;re&#44; Tindall and Cox"
                        "editorialLocalizacion" => "London"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "MR imaging of the metacarpophalangeal joints of the fingers&#58; part I&#46; Conventional MR imaging and MR arthrographic findings in cadavers"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "N&#46;H&#46; Theumann"
                            1 => "C&#46;W&#46; Pfirrmann"
                            2 => "J&#46;L&#46; Drap&#233;"
                            3 => "D&#46;J&#46; Trudell"
                            4 => "D&#46; Resnick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/radiol.2222010181"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiology"
                        "fecha" => "2002"
                        "volumen" => "222"
                        "paginaInicial" => "437"
                        "paginaFinal" => "445"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11818611"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Metacarpophalangeal joints at US in asymptomatic volunteers and cadaveric specimens"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "N&#46; Boutry"
                            1 => "A&#46; Lard&#233;"
                            2 => "X&#46; Demondion"
                            3 => "B&#46; Cortet"
                            4 => "H&#46; Cotten"
                            5 => "A&#46; Cotten"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/radiol.2323031075"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiology"
                        "fecha" => "2004"
                        "volumen" => "232"
                        "paginaInicial" => "716"
                        "paginaFinal" => "724"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15229348"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The sagittal band&#58; anatomic and biomechanical study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46;M&#46; Young"
                            1 => "G&#46;M&#46; Rayan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/jhsu.2000.18495"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hand Surg Am"
                        "fecha" => "2000"
                        "volumen" => "25"
                        "paginaInicial" => "1107"
                        "paginaFinal" => "1113"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11119670"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Proximal interphalangeal joint volar plate configuration in the crimp grip position"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "T&#46; Bayer"
                            1 => "A&#46; Schweizer"
                            2 => "M&#46; M&#252;ller-Gerbl"
                            3 => "G&#46; Bongartz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhsa.2012.02.016"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hand Surg Am"
                        "fecha" => "2012"
                        "volumen" => "37"
                        "paginaInicial" => "899"
                        "paginaFinal" => "905"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22480508"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The sesamoids of the metacarpo-phalangeal joint of the thumb&#58; an anatomical and clinical study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;D&#46; Gibeault"
                            1 => "P&#46; Saba"
                            2 => "H&#46; Hoenecke"
                            3 => "A&#46; Graham"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hand Surg Br"
                        "fecha" => "1989"
                        "volumen" => "14"
                        "paginaInicial" => "244"
                        "paginaFinal" => "247"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2746129"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Extensor mechanism of the fingers&#46; MR Imaging-anatomic correlation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Clavero"
                            1 => "P&#46; Golan&#243;"
                            2 => "O&#46; Fari&#241;as"
                            3 => "X&#46; Alomar"
                            4 => "J&#46;M&#46; Monill"
                            5 => "M&#46; Esplugas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/rg.233025079"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiographics"
                        "fecha" => "2003"
                        "volumen" => "23"
                        "paginaInicial" => "593"
                        "paginaFinal" => "611"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12740463"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The thickness of the sagittal bands in volunteers&#58; high resolution ultrasound of the fingers"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Kichouh"
                            1 => "M&#46; De Maeseneer"
                            2 => "T&#46; Jager"
                            3 => "S&#46; Marcelis"
                            4 => "E&#46; Van Hedent"
                            5 => "J&#46; De Mey"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00276-010-0693-6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Surg Radiol Anat"
                        "fecha" => "2011"
                        "volumen" => "33"
                        "paginaInicial" => "65"
                        "paginaFinal" => "70"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20632175"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The anatomy of the dorsal aponeurosis of the human finger and its functional significance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;N&#46;F&#46; Landsmeer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anat Rec"
                        "fecha" => "1949"
                        "volumen" => "104"
                        "paginaInicial" => "31"
                        "paginaFinal" => "44"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18149912"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The extensor apparatus of the finger"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46; Wheeler Haines"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Anat"
                        "fecha" => "1951"
                        "volumen" => "85"
                        "paginaInicial" => "251"
                        "paginaFinal" => "259"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14850394"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The dorsal aponeurosis&#44; intrinsic&#44; hypothenar&#44; and thenar musculature of the hand"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46;P&#46; von Schroeder"
                            1 => "M&#46;J&#46; Botte"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Orthop"
                        "fecha" => "2001"
                        "volumen" => "383"
                        "paginaInicial" => "97"
                        "paginaFinal" => "107"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11210974"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The functional anatomy of the extensor mechanism of the finger"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46; Harris Jr&#46;"
                            1 => "G&#46;L&#46; Rutledge Jr&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Bone Joint Surg"
                        "fecha" => "1972"
                        "volumen" => "54"
                        "paginaInicial" => "713"
                        "paginaFinal" => "726"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5055166"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomy of the intrinsic hand muscles revisited&#58; part I&#46; Interossei"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46; Eladoumikdachi"
                            1 => "P&#46;L&#46; Valkov"
                            2 => "J&#46; Thomas"
                            3 => "D&#46;T&#46; Netscher"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.PRS.0000024442.72140.56"
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2002"
                        "volumen" => "110"
                        "paginaInicial" => "1211"
                        "paginaFinal" => "1224"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12360058"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The interosseous muscles&#58; the foundation of hand function"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "F&#46;E&#46; Liss"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.hcl.2011.09.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hand Clin"
                        "fecha" => "2012"
                        "volumen" => "28"
                        "paginaInicial" => "9"
                        "paginaFinal" => "12"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22117919"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Architectural properties of the first dorsal interosseous muscle"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "B&#46;W&#46; Infantolino"
                            1 => "J&#46;H&#46; Challis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1469-7580.2009.01196.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Anat"
                        "fecha" => "2010"
                        "volumen" => "216"
                        "paginaInicial" => "463"
                        "paginaFinal" => "469"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20070422"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomy of the intrinsic hand muscles revisited&#58; part II&#46; Lumbricals"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46; Eladoumikdachi"
                            1 => "P&#46;L&#46; Valkov"
                            2 => "J&#46; Thomas"
                            3 => "D&#46;T&#46; Netscher"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg"
                        "fecha" => "2002"
                        "volumen" => "110"
                        "paginaInicial" => "1225"
                        "paginaFinal" => "1231"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12360059"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Development and morphogenesis of human wrist joint during embryonic and early fetal period"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Hita-Contreras"
                            1 => "A&#46; Mart&#237;nez-Amat"
                            2 => "R&#46; Ortiz"
                            3 => "O&#46; Caba"
                            4 => "P&#46; Alvarez"
                            5 => "J&#46;C&#46; Prados"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1469-7580.2012.01496.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Anat"
                        "fecha" => "2012"
                        "volumen" => "220"
                        "paginaInicial" => "580"
                        "paginaFinal" => "590"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22428933"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomy and function of lumbrical muscles"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46; Palti"
                            1 => "M&#46; Vigler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.hcl.2011.09.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hand Clin"
                        "fecha" => "2012"
                        "volumen" => "28"
                        "paginaInicial" => "13"
                        "paginaFinal" => "17"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22117920"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomic variations in the first extensor compartment of the wrist&#58; accuracy of US"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46; Rousset"
                            1 => "V&#46; Vuillemin-Bodaghi"
                            2 => "J&#46;D&#46; Laredo"
                            3 => "C&#46; Parlier-Cuau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/radiol.10092265"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiology"
                        "fecha" => "2010"
                        "volumen" => "257"
                        "paginaInicial" => "427"
                        "paginaFinal" => "433"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20829530"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "MRI features of intersection syndrome of the forearm"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46;R&#46; Costa"
                            1 => "W&#46;B&#46; Morrison"
                            2 => "J&#46;A&#46; Carrino"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2214/ajr.181.5.1811245"
                      "Revista" => array:6 [
                        "tituloSerie" => "AJR Am J Roentgenol"
                        "fecha" => "2003"
                        "volumen" => "181"
                        "paginaInicial" => "1245"
                        "paginaFinal" => "1249"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14573413"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intersection syndrome&#58; MR imaging with anatomic comparison of the distal forearm"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;E&#46; de Lima"
                            1 => "H&#46;J&#46; Kim"
                            2 => "F&#46; Albertotti"
                            3 => "D&#46; Resnick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00256-004-0832-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Skeletal Radiol"
                        "fecha" => "2004"
                        "volumen" => "33"
                        "paginaInicial" => "627"
                        "paginaFinal" => "631"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15365785"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound assessment of transverse carpal ligament thickness&#58; a validity and reliability study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Z&#46;L&#46; Shen"
                            1 => "Z&#46;M&#46; Li"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ultrasmedbio.2012.02.021"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ultrasound Med Biol"
                        "fecha" => "2012"
                        "volumen" => "38"
                        "paginaInicial" => "982"
                        "paginaFinal" => "988"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22502882"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomical study of the median nerve in the carpal tunnel and etiologies of the carpal-tunnel syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "H&#46; Robbins"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Bone Joint Surg Am"
                        "fecha" => "1963"
                        "volumen" => "45"
                        "paginaInicial" => "953"
                        "paginaFinal" => "966"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14047366"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The microvacuolar system&#58; how connective tissue sliding works"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;C&#46; Guimberteau"
                            1 => "J&#46;P&#46; Delage"
                            2 => "D&#46;A&#46; McGrouther"
                            3 => "J&#46;K&#46; Wong"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Hand Surg Eur"
                        "fecha" => "2010"
                        "volumen" => "35"
                        "paginaInicial" => "614"
                        "paginaFinal" => "622"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Permeability of the subsynovial connective tissue in the human carpal tunnel&#58; a cadaver study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "N&#46; Osamura"
                            1 => "C&#46; Zhao"
                            2 => "M&#46;E&#46; Zobitz"
                            3 => "K&#46;N&#46; An"
                            4 => "P&#46;C&#46; Amadio"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Biomech"
                        "fecha" => "2007"
                        "volumen" => "22"
                        "paginaInicial" => "524"
                        "paginaFinal" => "528"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The anatomy of the distal ulnar tunnel"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46;S&#46; Gross"
                            1 => "R&#46;H&#46; Gelberman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Orthop Relat Res"
                        "fecha" => "1985"
                        "volumen" => "196"
                        "paginaInicial" => "238"
                        "paginaFinal" => "247"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3995823"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomy of the palmar branch of the ulnar nerve&#58; application to ulnar and median nerve decompressive surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46;S&#46; Tubbs"
                            1 => "J&#46;M&#46; Rogers"
                            2 => "M&#46; Loukas"
                            3 => "A&#46; C&#246;mert"
                            4 => "M&#46;M&#46; Shoja"
                            5 => "A&#46;A&#46; Cohen-Gadol"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/2010.3.JNS091249"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg"
                        "fecha" => "2011"
                        "volumen" => "114"
                        "paginaInicial" => "263"
                        "paginaFinal" => "267"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20367079"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Magnetic resonance neurography of median neuropathies proximal to the carpal tunnel"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46;K&#46; Thawait"
                            1 => "T&#46;K&#46; Subhawong"
                            2 => "S&#46;K&#46; Thawait"
                            3 => "G&#46; Andreisek"
                            4 => "A&#46;J&#46; Belzberg"
                            5 => "J&#46; Eng"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00256-012-1380-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "Skeletal Radiol"
                        "fecha" => "2012"
                        "volumen" => "41"
                        "paginaInicial" => "623"
                        "paginaFinal" => "632"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22426804"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/1699258X/00000008000000S2/v1_201305061530/S1699258X12002422/v1_201305061530/en/main.assets"
  "Apartado" => null
  "PDF" => "https://static.elsevier.es/multimedia/1699258X/00000008000000S2/v1_201305061530/S1699258X12002422/v1_201305061530/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12002422?idApp=UINPBA00004M"
]

Información del artículo

ISSN: 1699258X
Idioma original: Inglés

DOI:10.1016/j.reuma.2012.10.004

Datos actualizados diariamente

año/Mes	Html	Pdf	Total

2024 Noviembre	20	3	23
2024 Octubre	336	132	468
2024 Septiembre	353	130	483
2024 Agosto	294	133	427
2024 Julio	367	100	467
2024 Junio	335	109	444
2024 Mayo	371	114	485
2024 Abril	379	83	462
2024 Marzo	509	90	599
2024 Febrero	431	106	537
2024 Enero	513	71	584
2023 Diciembre	303	83	386
2023 Noviembre	336	113	449
2023 Octubre	499	119	618
2023 Septiembre	550	99	649
2023 Agosto	267	89	356
2023 Julio	242	84	326
2023 Junio	228	73	301
2023 Mayo	313	111	424
2023 Abril	177	47	224
2023 Marzo	317	104	421
2023 Febrero	232	99	331
2023 Enero	218	75	293
2022 Diciembre	267	103	370
2022 Noviembre	288	82	370
2022 Octubre	224	71	295
2022 Septiembre	231	90	321
2022 Agosto	246	134	380
2022 Julio	201	119	320
2022 Junio	264	122	386
2022 Mayo	308	125	433
2022 Abril	273	117	390
2022 Marzo	308	137	445
2022 Febrero	234	115	349
2022 Enero	235	127	362
2021 Diciembre	233	121	354
2021 Noviembre	231	129	360
2021 Octubre	254	166	420
2021 Septiembre	218	142	360
2021 Agosto	239	159	398
2021 Julio	496	133	629
2021 Junio	304	156	460
2021 Mayo	265	138	403
2021 Abril	890	488	1378
2021 Marzo	492	228	720
2021 Febrero	349	189	538
2021 Enero	520	143	663
2020 Diciembre	355	146	501
2020 Noviembre	295	125	420
2020 Octubre	223	74	297
2020 Septiembre	259	130	389
2020 Agosto	156	89	245
2020 Julio	194	76	270
2020 Junio	255	98	353
2020 Mayo	272	88	360
2020 Abril	333	121	454
2020 Marzo	367	82	449
2020 Febrero	381	73	454
2020 Enero	269	75	344
2019 Diciembre	433	101	534
2019 Noviembre	321	89	410
2019 Octubre	430	98	528
2019 Septiembre	297	67	364
2019 Agosto	342	62	404
2019 Julio	357	60	417
2019 Junio	355	111	466
2019 Mayo	473	154	627
2019 Abril	308	93	401
2019 Marzo	284	58	342
2019 Febrero	302	43	345
2019 Enero	263	56	319
2018 Diciembre	376	58	434
2018 Noviembre	500	16	516
2018 Octubre	371	14	385
2018 Septiembre	332	12	344
2018 Agosto	383	18	401
2018 Julio	36	13	49
2018 Junio	0	1	1
2018 Mayo	39	7	46
2018 Abril	398	46	444
2018 Marzo	277	51	328
2018 Febrero	303	27	330
2018 Enero	196	37	233
2017 Diciembre	273	22	295
2017 Noviembre	236	32	268
2017 Octubre	211	49	260
2017 Septiembre	293	27	320
2017 Agosto	210	37	247
2017 Julio	229	46	275
2017 Junio	267	42	309
2017 Mayo	211	52	263
2017 Abril	174	48	222
2017 Marzo	247	98	345
2017 Febrero	233	97	330
2017 Enero	124	26	150
2016 Diciembre	190	50	240
2016 Noviembre	215	68	283
2016 Octubre	288	99	387
2016 Septiembre	257	120	377
2016 Agosto	83	83	166
2016 Julio	70	82	152
2016 Junio	1	0	1
2016 Marzo	1	0	1
2016 Febrero	4	0	4
2016 Enero	1	0	1
2015 Diciembre	1	0	1
2015 Noviembre	1	0	1
2015 Octubre	2	0	2
2015 Agosto	5	0	5
2015 Julio	169	8	177
2015 Junio	351	40	391
2015 Mayo	483	57	540
2015 Abril	472	84	556
2015 Marzo	530	72	602
2015 Febrero	500	28	528
2015 Enero	383	51	434
2014 Diciembre	368	39	407
2014 Noviembre	396	40	436
2014 Octubre	415	40	455
2014 Septiembre	320	48	368
2014 Agosto	294	46	340
2014 Julio	289	40	329
2014 Junio	304	48	352
2014 Mayo	368	12	380
2014 Abril	475	1	476
2014 Marzo	463	71	534
2014 Febrero	342	44	386
2014 Enero	388	54	442
2013 Diciembre	320	47	367
2013 Noviembre	284	38	322
2013 Octubre	288	43	331
2013 Septiembre	223	47	270
2013 Agosto	238	59	297
2013 Julio	206	66	272
2013 Junio	176	75	251
2013 Mayo	227	77	304
2013 Abril	169	109	278
2013 Marzo	214	149	363
2013 Febrero	204	121	325
2013 Enero	157	208	365
2012 Diciembre	20	25	45

Mostrar todo

Indexada en:

Síguenos:

Suscribirse:

Estadísticas

Indexada en:

Síguenos:

Suscribirse:

Estadísticas

Suscríbase a la newsletter