Emeritus Professor of Surgery (Orthopaedics)
John A. Burns School of Medicine
The Journal of Techniques in Hand
Division of Orthopaedic Surgery
San Diego VA Health Care System
Department of Orthopaedic Surgery
University of California, San Diego
Illustrated by Elizabeth Roselius
with contributions by Christy Krames
Acquisitions Editor: Robert Hurley
Developmental Editor: Keith Donnellan
Production Editor: Thomas J. Foley
Manufacturing Manager: Benjamin Rivera
Cover Designer: Christine Jenny
Compositor: Lippincott Williams & Wilkins Desktop Division
© 2003 by LIPPINCOTT WILLIAMS & WILKINS
as U.S. government employees are not covered by the above-mentioned copyright.
Library of Congress Cataloging-in-Publication Data
Surgical anatomy of the hand and upper extremity / James R. Doyle and Michael J. Botte.
Includes bibliographical references and index.
1. Hand—Anatomy. 2. Arm—Anatomy. I. Botte, Michael J. II. Title.
[DNLM: 1. Arm—anatomy & histology. 2. Hand—anatomy & histology. WE 805
Care has been taken to confirm the accuracy of the information presented and to describe generally
in view of ongoing research, changes in government regulations, and the constant flow of information
important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration
To Julie Kaye Frances and Robert E. Carroll, M.D., friends and mentors.
To my mother, Verona Louise Minning-Botte, M.D., and
my father, Joseph Michael Botte, M.D.
For their love, encouragement, and support
and for being the best teachers that I ever had.
Appendix 2.1. Muscles of the Hand and Forearm
and Arm: Origin, Insertion, Action, and
Appendix 2.2. Muscle Compartments and Fascial
Spaces of the Upper Extremity 183
Appendix 2.3. Human Forearm Muscle Difference
Index Values: A Comparison of Architectural
Features of Selected Skeletal Muscles of the Upper
Appendix 3.1. Dermatomes of the Upper
SECTION II: REGIONAL ANATOMY 295
Vincent R. Hentz and Y. Mark Hong
Richard A. Berger, James R. Doyle, and Michael J. Botte
Appendix: Anatomic Signs, Syndromes, Tests, and
Richard A. Berger, M.D., Ph.D. Professor, Departments of Anatomy and Orthopaedic
Surgery, Mayo Clinic, Rochester, Minnesota
Y. Mark Hong, B.S. Department of Surgery, Stanford University School of Medicine,
he or she had to go to many sources to glean a broad base of
anatomical knowledge. My own career illustrates this point.
As a medical student, I began with Gray’s massive and dry
tome, learning anatomy for the sake of anatomy, with no
clinical relevance. Then, as a resident, I discovered
its quaint Irish-English prose and manual mnemonics. As a
young surgeon, I sought out books that would give me quick,
snapshot glimpses of anatomy that I could memorize and
carry in my head at least until the next day in the operating
room. Grant’s Atlas was the first of these, which was later
such as Sunderland and Spinner have described wonderfully
detailed and precise anatomy, but with a limited focus.
Now the hand and upper extremity surgeon has what all
Hutchings have been blended into one unified source.
More than sixty crisp photographic prints depict
detailed cadaver anatomy with a precision and clarity that
but also replete with clinical applications.
Another pleasant surprise in this text is the appendix of
anatomic signs, syndromes, tests, and eponyms, where even
the surgeon who has studied the history of surgery will find
new or more accurate information. Practical lessons in the
One of the authors, James R. Doyle, was the first to
describe in detail the flexor pulley system in the fingers
details better than most of us, with an inherent tenacity fired
even harder during a fellowship year with Robert E. Carroll,
and with an exquisite and careful attention to detail. This
book is the culmination of his life-long dedication.
Michael Botte, his co-author, brings to this project the
thoroughness and precision of a true scientist, and his input
the entire surgical community, but our patients as well.
Every serious hand surgeon will find a readily accessible
spot on his or her bookshelf for this text.
the hand and upper extremity surgeon in the evaluation and
treatment of patients. A comprehensive knowledge of
anatomy is a major prerequisite for safe and effective
hand therapists, anatomists, neurologists, neurosurgeons,
sports medicine surgeons and physicians, physiatrists, and
bioengineers because it is a compendium of anatomic
knowledge. The science of anatomy and the art of surgical
appropriate, and complementary to the goal of the book.
a unique and current collection of material, which may not
be conveniently found elsewhere. Much of the information
can be found in other resources such as texts and journals
now need to review or utilize in a timely fashion, will come
to value this comprehensive resource. Our primary goal in
this text is to provide a readily available source for this
information that is user friendly, easily portable, and clinically relevant.
We hope that the arrangement, clarity, and brief yet
readily admit that paraphrasing and adoption of others’
original concepts have been used (although we have done
here, “When a thing has been said and said well, have no
scruples, take it and copy it.”
The text is divided into sections on Systems Anatomy
and Regional Anatomy, followed by an Appendix on
anatomic landmarks, relationships, surgical approaches,
clinical correlations, and the anatomy of selected anatomic
variations found in that region. The student of anatomy
will also recognize the immense value of the systems
approach, found in the section on Systems Anatomy, in
providing a comprehensive and overall view of a given
The authors take great pride in the color photographs of
fresh cadavers used in this text. A quote by Emanuel
Kaplan, about color photographs, from his foreword to
Milford’s 1968 classic monograph on Retaining Ligaments of
the Digits of the Hand seems appropriate here as well, “The
natural color illustrations add precision and eliminate the
imaginary interpretive creativity leading to error.” We hope
that the quality of our color photography can approach that
of Milford and warrant the affirmation of Kaplan on the
value of natural color photographs. We hope these color
photographs, along with the excellent illustrations, will
forms along with the descriptive text will provide the reader
with appropriate information, which will permit accurate
preoperative evaluation, diagnosis, and effective surgical
This fact should immediately indicate to the reader that
portrayed as lying side by side when in reality they may be
vertically arrayed. A good example is the usual depiction of
the radial and ulnar arteries in the proximal forearm. The
ulnar artery is depicted as lying to the ulnar side of the
radial artery in the same anatomic plane whereas, in reality,
the ulnar artery is deep and ulnar to the radial artery and is
often difficult to find. The reader should also note that the
and that the list of variations is not encyclopedic.
Reported differences in anatomy may be due to
anatomic variations as well as inter-observer variability and
subsequent interpretation of the observation. It would seem
reasonable to assume that all observers of a particular region
or segment of anatomy would see or observe the same
things and interpret what they saw in a similar uniform
fashion. Such is not the case, and although many points of
anatomy are agreed upon there are many that are not. Two
illustrative examples come readily to mind: (1) the arcade of
Struthers’ in the arm and (2) the location of the sesamoid
bones about the MP joint of the thumb. Some authors
describe in detail the arcade of Struthers’ 8 cm above the
medial humeral epicondyle and attach clinical significance
to it as a potential site of ulnar nerve compression in the
arm. Others claim that it does not exist or at least that they
have never seen it and thus it has no clinical relevance. The
location of the ulnar and radial sesamoid bones about the
MP joint of the thumb have been reported to be in the
humorous, analogy of six blind persons examining a camel.
Each of their descriptions are based upon their particular
location about the camel. Their significant inter-observer
observation as well as faulty interpretation. Thus, there may
be a lively correspondence and commentary generated by
likely to be encountered in the day to day practice of
surgery. Studies with small numbers of specimens in which
several patterns or categories of anatomical arrangement are
noted tell us that significant variation exists. It may not tell
us the true incidence of a given pattern or arrangement in
spite of the authors’ conscientious reporting of one, two, or
three cases in their series which demonstrated a particular
pattern or arrangement. Such studies though, are still
important and tell us that significant variation exists in that
particular structure or region and that the surgeon must be
prepared to encounter such an arrangement or even a new
and unreported pattern or arrangement.
By now, the reader has begun to appreciate the fact that
anatomy is not a “fixed” science, but rather an evolving or
developing endeavor with many remaining challenges and
All authors have their own methods for placing thoughts
on paper. This quote from Wallace Stegner1, although
directed at the writer of autobiography or fiction, seems
appropriate, “You take something that is important to you,
something you have brooded about. You try to see it as
clearly as you can, and to fix it in a transferable equivalent.
All you want in the finished print is the clean statement of
the lens, which is yourself, on the subject that has been
anatomic findings in the upper extremity and to our many
mentors and colleagues who have taught, encouraged, and
Finally, the authors wish to acknowledge their debt to
Robert Hurley and Keith Donnellan of the editorial staff at
Lippincott Williams & Wilkins who have patiently guided
Elizabeth Roselius, medical artist, for her understanding of
complex anatomic concepts and her ability to convert those
concepts into clear and concise drawings.
1 Stegner WE, Where the bluebird sings to the lemonade springs. New
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