Upper Limb

Question 1

Which tendons of the fingers are contained within a sheath? What is the clinical significance of this?

Answer 1

The flexor tendons are contained within synovial sheaths in the hand, whereas
the extensor tendons are not. These sheaths extend from the A1 pulley in the
palm to the A5 pulley at the distal interphalangeal joint of the fingers. The
membranous layer of the flexor sheath for the thumb and little finger often
extends further proximally into the wrist to form the radial and ulnar bursae.
Infection within the flexor sheath (flexor tenosynovitis) can be severe and
necessitates urgent surgical drainage and washout. Infections here can be so
devastating for two reasons. First, the rigid fibro-osseous tunnel of the flexor
sheath cannot expand in the presence of pus. This leads to raised pressure and
subsequent interruption of the blood supply to the flexor tendons. The late
sequelae are atrophic tendon ruptures. Second, the resultant scarring within the
flexor sheath following infection leads to adhesions between the tendons and the
sheath. This leads to reduced tendon excursion, stiffness and loss of function.

Question 2

Describe the pathological process that commonly affects the palmar fascia

Answer 2

The palmar aponeurosis seems to be susceptible to progressive hyperplasia and
fibrosis, with subsequent thickening and shortening. This leads to a flexion
deformity of one or more of the digits, with associated loss of function. This
condition is known as Dupuytren’s contracture.

Question 3

What are the posterior relations of the kidney?

Answer 3

Diaphragm
Quadratus lumborum
Psoas major
Transversus abdominis