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The Historical Importance of the Hand in Advancing the Study of Human Anatomy

Posted on: Sunday, 3 April 2005, 03:00 CDT

Anatomy is often considered the foundation of medical science and is basic to the education of health professionals. This report will attempt to summarize the history of anatomy from antiquity to modern times. In addition it will highlight the historical importance of the upper extremity and its relationship to the development of human anatomy as a recognized medical science. (J Hand Surg 2005;30A:209- 221. Copyright 2005 by the American Society for Surgery of the Hand.)

Key words: Anatomy, hand surgery, history, upper extremity.

Anatomy, the oldest medical science, derives its name from the Greek word anatamnein (to cut, to dismember). The history of anatomy extends back to ancient civilizations, where rudimentary dissections were performed to understand human form and function. Over time anatomy evolved into a respected scientific discipline that now figures prominently in medical education, and a thorough understanding of anatomy is crucial to the field of hand and upperextremity surgery.

The dissection and portrayal of the upper extremity holds a unique place in the history of anatomy. As Aristotle eloquently stated, the hand is the "instrument of instruments" and is "for the body as the intellect is for the soul."' In Renaissance Europe the hand was revered as God's most profound creation.2 The most famous example of this prevailing attitude is illustrated by Rembrandt van Rijn's masterpiece The Anatomy Lesson of Dr Nicolaas Tulp (1632) (Fig. 1). In this painting the eminent surgeon stands surrounded by students as he demonstrates the workings of the forearm muscles and tendons. Despite debate over the origin of the forearm flexor muscle mass as depicted in this painting3-5 dissection of the upper extremity clearly was important to anatomists.

The purpose of this report is to trace the role of the hand and upper extremity within the context of the history of gross anatomy. Some of the most wellknown anatomists have attached special meaning to the dissection of the hand and forearm. Momentous discoveries have also been aided by using the upper extremity as an experimental model. Only by understanding anatomy's historical backdrop can one grasp the importance of the discoveries made in the upper extremity. It is our hope that the information presented here will help readers better appreciate our craft.

Ancient Civilizations

The oldest known systematic study of human anatomy is contained in an Egyptian papyrus dating from 1600 BC. The accumulation of anatomic knowledge can be attributed to the sheer number of bodies embalmed in ancient Egyptian civilization. It has been estimated that over 70 million bodies were preserved in this fashion. The papyrus suggests that the heart, vessels, liver, spleen, kidneys, ureters, and bladder were recognized.6-8 There is no record, however, of any study of the extremities.

Figure 1. Rembrandt van Rijn's The Anatomy Lesson of Dr. Nicolaas TuIp (1632). (By permission of Mauritshuis, the Hague. Photo credit: Scala/Art Resource, NY.)

In ancient Chinese civilization anatomic theories were attained by reasoning and by assumption rather than through direct observation. Because the doctrines of Confucius (551-479 BC) forbade violation of the body the Chinese did not begin systematic, direct anatomic studies until the early 18th century.7,9 Until that point many anatomic illustrations were concerned solely with the vascular system of the arm because the Chinese placed great importance on the examination of pulses. In fact a patient's symptoms, diagnosis, and prognosis could be derived from a thorough examination of pulses in the upper extremity.6

In ancient India Susruta (6th century BC), often considered the father of modern-day plastic surgery, encouraged physicians to acquire knowledge of the structure of the human body to become effective at their work. To circumvent Hindu religious laws that forbade touching the deceased other than for purposes of cremation Susruta instructed that a body be wrapped in grass and placed in a cage. The body would then be secured in a slowly moving river and allowed to decompose. After seven days, the body would be removed from the cage and scrubbed with a whisk made of grass roots to expose the deeper layers of tissue.7 By this method the internal organs could be disclosed without using a knife, which was prohibited by religious law.9 From his anatomic studies Susruta established his theory on marmas, described as special points on the body where penetrating injuries could prove fatal or seriously damaging.6 Many such points were described in the upper extremity although locations have been described over the entire body.

Among the classical Greeks what was known of human anatomy was more rational than superstitious or religious. Knowledge of anatomy, however, was limited and was derived chiefly from butchering, sacrifices, or battle injuries. Moreover, human dis section was not practiced and was banned because of existing laws, customs, and prejudices.9

Hippocrates (460-377 BC), regarded universally as the father of western medicine, postulated that anatomy served as the foundation of medicine. He also believed, however, that healers could learn sufficient anatomy by observing wounds without "the unpleasant if not cruel task" of dissecting corpses.7 Of the works ascribed to Hippocrates none are devoted expressly to the study of anatomy although they show that Hippocrates had some accurate notions on osteology. The bulk of his treatise On Fractures includes instructions explicit to the management of upperextremity fractures. Hippocrates also explores dislocations in the upper extremity in his tract On the Articulations, which includes techniques for reduction of a dislocated shoulder, elbow, wrist, and finger. He states that a "dislocation at the joint of a finger is easily recognized. Reduction is to be effected by making extension in a straight line, and applying pressure on the projecting bone, and counterpressure on the opposite side of the other."10 Despite his contributions to the study of skeletal anatomy Hippocrates harbored superficial or erroneous ideas about other structures of the human body. For example, he was unaware of the existence of the nervous cords and he used the term "nerve"-as did Grecian doctors in general-to signify a sinew or tendon.7

Aristotle (384-322 BC), the greatest philosopher of his era, was not actually a physician. Nevertheless he studied and dissected the anatomy of animals, laying down the foundation for the study of comparative anatomy. Two of his works, De partibus animalium (Parts of Animals) and Historia animalium (History of Animals), constitute remarkable anatomic investigations.7 These studies may have led Aristotle to declare that the hand, together with reason and speech, is one of the 3 ways in which man differs from other animals. Like Hippocrates, however, Aristotle's knowledge of human anatomy was based on external observations and speculative ideas obtained from dissecting lower animals.7

Despite the Greeks' prejudices against the practice of human dissection they were not averse to having dissections performed in one of their conquered territories, namely in the Greek colony of Alexandria in Egypt. A school of medicine was established there and flourished for several centuries. Two pioneering anatomists, Herophilus (350-280 BC) and Erasistratus (310-250 BC), were among the first to dissect human bodies.9 Herophilus was the first person to dissect bodies after death for the purpose of characterizing the course of disease-the earliest known autopsies-and was perhaps the first truly scientific student of human anatomy.7,9 Not much is known of his life and all of his writings including his book On Anatomy have been destroyed. Apart from anatomic descriptions another important contribution from the Alexandrian school was a pair of complete skeletons assembled by Herophilus and Erasistratus. These skeletons were probably the first ever assembled for the purposes of studying human osteology and they survived for centuries as physicians traveled from afar to study these figures.7 Clearly Herophilus and Erasistratus made important contributions to the science of anatomy; however, many of the accomplishments of these early anatomists were eclipsed by Galen's work.

The most influential medical writer of all time was Claudius Galen (131-201 AD), a Greek physician practicing in Italy whose anatomic observations dominated medical science for 1400 years from the Roman era to the Renaissance. In his treatises he gave detailed anatomic descriptions from dissections that were performed usually on Barbary apes, pigs, dogs, and bears. Because dissection of the human body was still banned Galen resorted to chance opportunities to document his observations of deep injuries and of abandoned and fortuitously discovered human corpses.9,11,12

Galen devoted a major portion of his work to the anatomy and function of the hand; he was first physician and anatomist to do so. In his book De ossibus ad tirones (On Bones for Beginners) Galen used an anatomic nomenclature that included terms like epiphysis, apophysis, phalanx, metacarpus, and carpus, although such terms may not have been coined by him.13,14 At the age of 28 he became a surgeon for gladiators and proposed successful new treatments for injured tendo\ns and nerves.15 He recognized that tendons are "surrounded by sheaths that protect them from injury and from attrition by the bones."16 He also documented the division of the flexor tendons into the superficial and deep parts. The "sublimis tendons," he noted, "make the second phalanx move, whereas the profundus ones flex not only the third phalanx, but the whole finger. Profundus tendons are therefore more important than the sublimis, because if a sublimis tendon is damaged, an intact profundus is enough for complete functioning of the finger."16 In fact, Galen begins his principal anatomic essay, De usu partium (On the Usefulness of the Parts of the Body), with the hand. It was the muscles of the hand and forearm that, in his view, presented the unanswerable argument that there was design in Nature and that man was the high point of that design.2

The Middle Ages

After the Arabian conquest of Alexandria in 642 AD many Greek medical texts came into Arab possession and were translated and studied. In this way the medical tradition of the ancients was preserved during the Middle Ages but little was added to the canon. The main obstacle to the progress of anatomic knowledge during this period was the proscription of post mortem dissections under Islamic law. In the west the Christian church also strongly opposed dissection.9 A papal decree that prohibited the Crusaders from boiling the bones of their fallen brethren and returning them to Europe was zealously extended to all dissection. Surgery also ceased to be a part of the intellectual mainstream of medical life and thought.14

Figure 2. Anatomic figure from the late Middle Ages. The general muscle masses are distinguished but not the individual muscles. Croups of muscles for raising and lowering the arm are illustrated, as they are for the lower extremities. (By permission of the Bodleian Library, University of Oxford. MS. Ashmole 399, fol. 22r.)

When the first European medical school was founded in Salerno, Italy, in 1235 teaching was based on Arabian sources derived from the Galenic canon and practical anatomy was based on the dissection of animals. It was not until the latter part of the 13th century and particularly in the 14th century that the civil and ecclesiastic laws governing dissection were relaxed. In 1303 the first recorded judicial autopsy was carried out in Bologna and by the end of the century public dissections were being performed legally in Venice, Florence, and Montpellier,9,12 usually limited to 1 per year and performed on an executed criminal.

Despite the fact that dissections were fairly widespread by the mid-15th century progress in anatomic illustration was negligible. Typically, anatomic figures consisted of crude schematic drawings, certainly not based on scientific observation and therefore practically useless as serious teaching instruments (Fig. 2). Drawings showed a rudimentary understanding of muscle location such as the location of the deltoids but they did not imply a sophisticated understanding of muscle attachments or muscle contour.11 Usually anatomic illustrations were purposefully vague enough to perpetuate the anatomy of Galen or used to depict the ceremonial nature of anatomy.17 In addition there was no perceived need for medieval physicians to understand the finer points of limb anatomy other than to know preferred areas for bloodletting, which was a common treatment modality during that era.

The invention of the printing press represented one of the most monumental advances in the history of civilization. The diffusion of knowledge by word of mouth, letter writing, and the laborious copying of manuscripts was replaced by the comparatively facile duplication of copies by printing presses. In the first few decades of printing many medical texts were issued but few of them were illustrated. The first medical text with illustrations of any significance was Johann de Ketham's Fasciculus medicinae, printed at Venice in 1491.17 The earliest known print of the human skeleton dates to 1493 (Fig. 3).7,11 The skeleton is associated with the name Richard Helain and inspection of the phalanges shows wires between the bones, suggesting that a real human skeleton had served as a model for this illustration.

The Renaissance

The Renaissance period heralded an unprecedented acquisition of knowledge not only in the arts and literature but also in science, including anatomy. Renaissance artists became increasingly interested in the human form and the study of anatomy became necessarily part of a young artist's apprenticeship, especially in Northern Italy. The advent of shading and perspective during the Renaissance endowed the artist with the ability to render realistic 3-dimensional images, which helped to portray accurately the structures of the human body. Michelangelo Buonarroti (1475-1564) spent at least 12 years in serious study of anatomy through personal dissections.6 In fact, it is said that Michelangelo eventually "gave up dissecting corpses because his long handling of them had so affected his stomach that he could neither eat nor drink salutarily."18 Nevertheless, anatomic dissection provided Michelangelo with an unparalleled perspective of the human form.

Figure 3. Earliest known print of a human skeleton in Magnus Hundt's Antropologium (1501), probably derived from the print attributed to Richard Helain (Neurenberg 1493). (By permission of the British Library, London IA.22560.(1), 543.a.26.)

Figure 4. (A) Movements of the arm bones produced by muscles, especially the biceps, as illustrated by Leonardo da Vinci. (B) Detail of superficial blood vessels in an arm. (By permission of the Royal Collection (c) 2004, Her Majesty Queen Elizabeth II.)

Most Renaissance artists were anatomists only secondarily, learning the human form mainly for artistic purposes. Leonardo da Vinci (1452-1519), however, was the first artist to delve into the study of anatomy beyond its practicality in depicting the intact human body. He detailed various structures of the body and paid particular attention to the musculoskeletal, nervous, and vascular systems in his drawings (Fig. 4). Da Vinci often resorted to views from above and below of the same anatomic part or, as in the case of the long bones of the arm, he focused on their mechanical function as levers for lifting, lowering, rotating, and bending.17,19 Muscles were revealed in layers, leaving no doubt as to their correct shape and attachment to the bones, and it is to him that we owe our first cross-sectional drawings in anatomy.7 Many of his drawings also show deep insight into the opposing functional groupings of muscles. Unfortunately, his numerous depictions of the human body were not published until the early 19th century and therefore did not receive the same recognition as the work of a Renaissance contemporary, Vesalius.

The name of Belgian anatomist Andras Vesalius (1514-1564) will always be associated with the revival of anatomy in modern times. Vesalius' approach to anatomic dissection differed from his predecessors in that he dissected with his own hands and did not teach from a pulpit while referring to Galen, as was the custom in his day.9 He has been called the father of modern anatomy because the main task of his academic life was to revolutionize the teaching of human anatomy and to overthrow the prevailing Galenic canon. He challenged the teachings of Galen, many of which were still staunchly held beliefs centuries later, and showed that Galen's findings were produced from animals and not from human dissections.6,8,9,12

Figure 5. (A) Andreas Vesalius' "Fourth Plate of the Muscles." (B) Vesalius' "Eleventh Plate of the Muscles." Both engravings originate from Vesalius' De humani corporis fabrics (1543). (By permission of the National Library of Medicine.)

Vesalius produced his greatest work, De humani corporis fabrica (On the Structure of the Human Body), in 1543. Described by Sir William Osier as "the greatest book ever printed, from which modern medicine dates," De humani corporis fabrica is the landmark contribution from which contemporary anatomic illustration originates.17 It features illustrations of the human body familiar to modern-day medical professionals and scientists for their artistic and technically accurate renderings of human anatomy (Fig. 5). One characteristic feature of all Vesalian figures is that the dissected body is represented in a dynamic fashion. Vesalius also paid great attention to dissection of the upper extremity. In his "Fourth Plate of the Muscles" (Fig. 5A) the dependent muscles in the right forearm are the flexor carpi radialis and the palmaris longus with the palmar fascia, which are removed on the left side. In the "Eleventh Plate of the Muscles" (Fig. 5B) the deltoid muscles are reflected, exposing the external rotators of the shoulder. On the dorsal aspect of the right forearm the obliquely placed muscles passing to the thumb and index finger have been turned back, exposing more clearly the supinator and the extensor carpi radialis longus and brevis.20

In fact, Vesalius placed such importance on dis section of the upper extremity that the only known first-hand likeness of Vesalius shows the formally attired anatomist grasping the dissected arm of a cadaver (Fig. 6). In this portrait the cadaver's arm appears deliberately large. It is supposed that this was done intentionally to emphasize the importance of the dissection.21 When Vesalius publically demonstrated a dissection he routinely began with the forearm and hand and he made this gesture his trademark. Like Galen, Vesalius believed that the anatomy of the hand and forearm provided demonstrable proof of Nature's design.2

The hand and upper extremity have also served as a valuable experimental model for important anatomic findings. William Harvey (1578-1657), an English doctor and court physician to King James I and later to King Charles I, publi\shed An Anatomical Study of the Motion of the Heart and of the Blood in Animals in 1628. In this book Harvey explained how blood was pumped from the heart throughout the body and then was returned to the heart and recirculated.22 To show that the vascular system was a complete pathway of circular movement he performed a simple experiment in the upper extremity to show that a connection existed between arterial and venous blood. He ligated a forearm extremely tightly so that no arterial blood could flow distal to the ligature in the arm. He then loosened it so that arterial blood could flow down the arm, although it remained tight enough to halt venous return above the ligature. With the ligature very tight the veins in the arm below it had appeared normal, but now they became swollen, showing that blood had passed down the arteries and then back up the arm within the veins. He was also able to demonstrate the action of the valves in veins using the upper extremity as an example (Fig. 7).8

Figure 6. Portrait of Andreas Vesalius from De humani corporis fabrica (1543). (By permission of the National Library of Medicine.)

During the 16th and 17th centuries gross anatomy evolved into a prominent part of the curriculum for medical education, as shown by Rembrandt's masterful painting (Fig. 1). During the 16th century the first public dissections took place in "anatomical theatres." These theatres were highly attended and continued well into the 17th century.9,12

The carpals were named in 1653 by Michael Lyser (1626-1659) of Denmark. Before Lyser's time Vesalius had identified each carpal by a numbering system only, which stood without challenge for 1 century. Over time Lyser's naming system was accepted gradually and modifications to the carpal nomenclature ensued with contributions by Alexander Monro (1697-1767), Bernard Albinus (1697-1770), and Frederich Gustav Jacob Henle (1809-1885).23,24 Multiple portrayals of the carpal bones had also emerged-most notably those of da Vinci (Fig. 4A), which were seen only by a few contemporaries at the time, and the Helain skeleton (Fig. 3), which appears crude by comparison. Before publication of De humani corporis fabrica illustrations of the hand often depicted the metacarpals as attached directly to the distal radius.

The study of gross anatomy had become a well established field of interest by the end of the Renaissance period. A number of anatomists from the Renaissance period extending to the present time have made eponymous contributions to the field of anatomy, particularly in the upper extremity (Table 1).25,26 By the end of the 18th century, however, interest in gross anatomy had waned. Most scientists' attention had turned to pathologic anatomy, comparative anatomy, and embryology.

Figure 7. Engraving from William Harvey's An Anatomical Study ot the Motion ot the Heart (1628) showing the action of valves in the forearm veins. (By permission of the National Library of Medicine.)

Table 1. Hand and Upper-Extremity Eponyms

Table 1. Hand and Upper-Extremity Eponyms

Recent Developments

Although da Vinci's early sketches indicated that he had toyed with the concept, cross-sectional anatomy was the invention of a 19th-century Russian surgeon, Nikolai Ivanovich Pirogov (1810- 1881). His work Atlas of Topographical Anatomy (1852) was based on cross-sections taken through frozen human cadavers (Fig. 8).27 For the first time spatial relationships, so important to surgeons, could be preserved while displaying the anatomy. When considered within the context of current imaging techniques Pirogov's contributions to the field of anatomy appear particularly prescient. The computerized axial tomography (CAT) scanner was invented in 1975; the first magnetic resonance imaging (MRI) scanner was constructed in 1977. Atlases of cross-sectional anatomy with CAT and MRI correlates followed shortly thereafter.28

Before the CAT scan or the MRI scan, however, the advent of another form of imaging would give the study of anatomy one of its most powerful tools-the x-ray. A chance discovery in 1895 led to the development of x-ray images by German physicist Wilhelm Konrad Roentgen (1845-1923). The announcement of Roentgen's discovery was illustrated with an x-ray photograph of his wife's hand (Fig. 9) and was immediately hailed as one of mankind's greatest technological accomplishments.8 The x-ray enabled anatomists to study tissues and organ systems in living animals for the first time. Within a year of Roentgen's discovery anatomists realized that the intercarpal joints actually imparted mobility to the wrist. The x-ray dispelled any notions that the carpal articulations were locked together as most anatomists had supposed from examining cadaveric specimens.29

Since the invention of these imaging modalities other technological advancements have improved our ability to learn and teach human anatomy. The development of motion photography and video facilitates visualization of dynamic information. Although these technologies have been largely underused they are gaining attention as a means of communicating select kinds of information. A recent article in the Journal of the American Academy of Orthopaedic Surgeons acknowledged the potential utility of video and discussed sophisticated techniques for digital video use.30 Journals such as the Journal of Hand Surgery and the Journal of Bone and Joint Surgery feature links on their websites that allow subscribers to access video content. Reverse motion photography allows for anatomy instruction in a conceptually logical sequence from the core elements to the complex complete limb rather than the age-old and conceptually awkward method of reducing a complete limb to its elemental structures.31

Figure 8. (A) Axial cross- section through the carpal tunnel. (B) Sagittal cross-section through the thumb, which is dislocated at the metacarpophalangeal joint. Both drawings are from Nikolai Pirogov's Atlas of Topographical Anatomy (1852). Printed with permission of the National Library of Medicine.

Figure 9. Wilhelm Roentgen's x-ray photograph of his wife's hand (1895). (By permission of the National Library of Medicine.)

The advent of the computer age has spawned programs that can teach and then quiz the participant on various topics. This has been a particularly useful tool with anatomy instruction. case studies presented on the computer can incorporate radiologic studies and digital images of cadaveric specimens. Students using the teaching programs can then test themselves to ascertain their level of knowledge or determine weak points. Medical schools are beginning to use such programs to supplement or even replace anatomy dissections. The Interactive Hand by Primal Pictures (London, England) is an example of such teaching aides available and presents 3-dimensional models of the hand and forearm.

Finally, the creation of the Internet has led to an explosion of accessible information. The influences of the Internet could be compared to the Gutenberg printing press in terms of facilitating access to information. With the use of search engines nearly any topic of interest can be investigated. One website accessible via the Internet is the Visible Human Project, which features complete 3- dimensional representations of male and female human bodies. Created in 1986 by the National Library of Medicine the website features transverse CAT, MRI. and cryosection images of male and female cadavers sectioned at 1-mm intervals and 0.33-mm intervals, respectively.32

The Future

New developments will continue to change the way anatomists and surgeons view the human body. Many of these advances will occur with the aid of computers, which will continue to contribute enhancements for imaging. Positron emission tomography, for example, represents a new scanning technique that uses radiation emitted from the patient's brain to develop an image and illustrate the brain at work in a conscious and alert patient. Positron emission tomography scans can help scientists study the chemical processes involved in the workings of a healthy or diseased brain in a way that was previously impossible. Before the advent of this imaging modality scientists could only infer what went on within the brain from post mortem dissections or animal studies.

Holography, another imaging technology, is also in its infancy in modern medicine. The major advantage of holography is that it can reproduce 3-dimensional spatial relationships accurately on a suitable photographic material using sets of laser beams. When visible light is reflected at an appropriate angle the original specimen can be viewed in its 3-dimensional entirety. Anatomists can make use of holography to show the 3-dimensional relationships of the body. In this way the study of the human body could continue to evolve beyond cross-sectional anatomy in depicting the spatial relationships of internal structures. Already holographic imaging has been used to produce 3-dimensional representations of the spine to assist with pedicle screw placement.33 Holography has also been used to depict the dynamic motion of the beating human heart.34 The use of holographic imaging could certainly benefit anatomists and hand surgeons wishing to characterize further the dynamic and complex motions of the wrist joint.

Magnetic resonance angiography is an MRI study that can provide detailed images of blood vessels using noninvasive means. For now it represents a useful way of inspecting patients for diseased intracranial arteries so that only those with positive findings will need to have more invasive studies. In the future it will be used likely on a routine basis to examine the small vessels of the hand and elucidate pathologic findings in the upper extremity. Magnetic resonance angiography has already proven useful as a diagnostic tool for characterizing a vascular malformation in the flexor tendon sheath of a hand.35

Magn\etic resonance neurography represents a new method for diagnosing problems related to the peripheral nerves. It is capable of generating a detailed image of virtually any nerve in the body and poses exceptional utility for hand surgeons evaluating patients with nerve compression. Magnetic resonance neurography has been shown to be an effective means of confirming both compression of the median nerve and its successful surgical decompression in patients with carpal tunnel syndrome.36 In addition to characterizing nerve compressions it can also aid in identifying nerve discontinuity and intraneural or perineural masses.37 Certainly it could conceivably replace or at least enhance electrodiagnostic studies.

Finally, it is imaginable that the study of anatomy will involve computer-assisted simulations in the future. Surgeries are already being aided by computer simulations. A virtual-reality shoulder arthroscopy simulator has been designed that facilitates discrimination of arthroscopic skills, providing a major opportunity for surgical skills development.38 Advances in the fields of medical imaging, computer vision, and robotics have provided the enabling technologies to permit computer-aided surgery to become an area that can address clinical needs.39 Although in its early stages joint replacement surgery already is moving in the direction of computer- assisted navigation systems. The potential benefits of computeraided surgery are an improvement in the accuracy of surgical interventions, less invasive surgeries, better planning and simulations, and the reduction of radiation exposure for both patient and surgeon.40

Clearly the study of anatomy has evolved over the centuries from its beginnings in antiquity. What is often not appreciated is the role the upper extremity has played in advancing the science of anatomy. The hand and upper extremity have always been viewed as a special entity unique to human beings. As such much importance has been attached to its dissection and understanding of its function. Some of the most famous and prolific anatomists have devoted a significant portion of their careers toward understanding the workings of the hand. With the current advances in imaging and computer technology we undoubtedly will continue to appreciate the complexity of the anatomy of the hand, the "instrument of instruments."

References

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Eon K. Shin, MD, Roy A. Meals, MD, Los Angeles, CA

From the Department of Orthopaedic Surgery, UCLA Center for Health Sciences, Los Angeles, CA.

Received for publication May 14. 2004; accepted in revised form September 21, 2004.

No benefits in any form have been received or will be received by a commercial party related directly or indirectly to the subject of this article.

Reprint requests: Roy A. Meals. MD. UCLA Center for Health Sciences, 100 Medical Pla/a Building. Ste 305. Los Angeles. CA 90095- 6970.

Copyright 2005 by the American Society for Surgery of the Hand

0363-5023/05/30A02-0001 $30.00/0

doi:10.1016/j.jhsa.2004.09.004

Copyright Churchill Livingstone Inc., Medical Publishers Mar 2005

Source: Journal of Hand Surgery, The

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