Anatomy Lesson #61: Jamie’s Mars and Scars

Hallo, anatomy students. First lesson posted in a while – I have been waiting for new S4 material!

Meantime, “Me keep do.”  So, here’s one last lesson from S3.  Welcome to Anatomy Lesson #61, Jamie’s Mars and Scars!

Getting right to it…. Many events transpired in ep 306, A. Malcolm, wherein Jamie meets Claire after two hundred and twenty-two years apart. Woot!

Like you, the intimate scenes of this episode immediately drew my eyes to Jamie’s body –  Oops, I mean his mars and scars. Come on, I’m a scientist! 

My anatomist’s eye immediately began calculating… Weil, actually not until the second viewing, but you get my drift…. Are Jamie’s scars all present? Are any scars missing? Are they accurately depicted? Did they change?

What say you, Outlander fans, shall we investigate?

This is a chronological list of injuries over three seasons of Outlander TV and most produce scars. All but one appear in the books. Do you ken the outlier?

  1. dislocated shoulder joint
  2. gunshot wound, front
  3. gunshot wound, back
  4. BJR backlash
  5. McDonald’s sword work
  6. BJR hand smashing
  7. BJR burn
  8. BJR Culloden scar

Truly, this red-heided lad has suffered his share of owies! 

We are all too aware of horrific wounds from modern warfare, but battlefield wounds have always been appalling. In the 16th century, French barber surgeon Ambrose Paré became famous for his ingenious repairs of battlefield injuries. One of his famous illustrations is a composite drawing that depictes the range of wounds suffered by warriors of the past (Image A). Seems as if our Jamie may have posed for this image. Gasp!

Image A

Just for fun and because you have nothing else to do <g>, let’s explore the laundry list of Jamie’s Wounds.  We’ll jump backward and forward 20 years as we analyze his mars and scars in chronological order.

Strap yourselves in. Here we go!

1. Dislocated Shoulder Joint:

Claire first spies Jamie perched atop a stool in a crofter’s cottage (Starz ep 101, Outlander). His hunched form cradles right forearm. Her keen nurse’s eye is horrified by his injury. Here from Outlander book:

I gasped, as did several of the men. The shoulder had been wounded; there was a deep ragged furrow across the top, and blood was running freely down the young man’s breast. But more shocking was the shoulder joint itself. A dreadful hump rose on that side, and the arm hung at an impossible angle.

Q: What happened to Jamie?

A: He suffered an anterior dislocation of the right shoulder joint.

His fellow Highlanders move to force the joint into place but Claire-Declares, NO!  No qualified chirurgeon in this grubby group of lads!

The dreadful “hump” is the acromion, a feature of the scapula (shoulder blade). Read about the shoulder joint and Claire’s treatment of its dislocation in Anatomy Lesson #2, When Claire Meets Jamie or How to Fall in Love While Reducing a Dislocated Shoulder Joint!

Footnote #1: In Outlander book, Jamie suffered both a dislocated shoulder and a gunshot wound. Diana wrote that the musket ball knocked him from the saddle and he fell on his hand. Crunch went the shoulder joint! 

Outlander ep 101, Sassenach

Although bruising and swelling often accompany such dislocations, both may resolve without sequelae. Jumping forward 20 years, witness Jamie’s fine form at the brothel reunion in Starz ep 306, A. Malcolm. Evidence of a shoulder dislocation? Nada! Fortunately for Claire, this shoulder works perfectly fine. In fact, everything works perfectly fine. Wink, wink!

Outlander ep 306, A. Malcolm

Before we leave the shoulder issue, several fans have asked if the TV depiction of Jamie’s dislocation is realistic. Well, mostly. An actual anterior dislocation of the shoulder joint looks like Image B (left shoulder). Here, the rounded contour of the shoulder is lost because head of the humerus has been displaced forward into the armpit area (axilla).  The bony knob (red arrow) is the acromion but, clearly, it is not as prominent as depicted in the TV version.

The difference can be explained because in the TV episode, the “dreadful hump” was a prosthetic applied to the top of Jamie’s shoulder. Thus, the hump sits higher and appears more prominent than in life. But, otherwise, kudos to the special effects team!

Image B

Moving on!

2. Gunshot Wound, Front:

Back to the crofter’s cottage! Hightailing it towards home, the Highlanders are ambushed by Redcoats at Cocknammon Rock. But, the English are swiftly dispatched. Hours later, Claire shouts:

“Stop! Help! He’s going over!”

Timber!!! – Jamie topples from his steed.

Claire swiftly discovers a gunshot wound. Jamie, why didn’t you fess up? Now, Claire must deal with a nasty hole left by a musket ball plowing a path through Jamie’s trapezius muscle! Claire explains to Dougal’s merry band of men (Outlander book): 

“The gunshot wound has been bleeding again, and the idiot’s been knifed as well. I think it’s not serious, but he’s lost quite a lot of blood. His shirt is soaked through, but I don’t know how much of it is his. He needs rest and quiet; we should camp here at least until morning.” 

Fat chance Dougal will stop for his nephew to rest; not with Captain Randall prancing through the heather.

“On your feet, soldier!” 

Footnote #2: The TV version shifted the gunshot wound later in the episode and completely ignored the knifing. Probably figured Claire had enough on her plate. Hah!

Outlander ep 101, Sassenach

Fast forward 20 years: Delightful! Starz FX team remembered to include a faint scar as evidence of that entrance crater left by the musket ball. 

Can’t you just see a Starz employee with a wound list?

  • Dislocated shoulder joint, check!
  • Front gunshot wound, check! (
  • etc.

Outlander ep 306, A. Malcolm

3. Gunshot Wound, Back:

Back to the past. Next morning, in Castle Leoch’s keep, wary Claire meets-and-greets wary Mrs. Fitz – immortalized  in this masterful excerpt from Outlander book:

“But he’s hurt. He was shot yesterday and stabbed last night. I bandaged the wound for riding, but I didn’t have time to clean or dress it properly. I must care for it now, before it gets infected.” 

“Infected?”

“Yes, that is, I mean, inflamed, you know, with pus and swelling and fever.”

“Oh, aye, I know what ye mean. But do ye mean to say as ye know what to do for that? Are ye a charmer then? A Beaton?”

“Something like that.”

This terse little tête-à-tête, wherein WWII combat nurse and 17th century castle housekeeper face-off, reveals Claire’s nimble brain! The term infected, meaning invasion by micro-organism, won’t come into common use for another century. Oops, she quickly course-corrects! 

Then, off she goes to properly tend Jamie. (One might think the lad is accident prone!)

The wound at back of shoulder marks the exit site of the musket ball. Serious bruising from gunshot wound and dislocated shoulder and horrific criss-crossing scars (see below) definitely catch her eye. Eek!

Outlander ep 102, Castle Leoch

Spring forward 20 years. Was the exit wound depicted at the brothel reunion? Aye, it was. Take a really close keek at Jamie’s back….there it be (red arrow).

Psst…let’s just ignore the unfortunate pleating of Jamie’s back prosthesis – best save those pleats for his kilt.

Outlander ep 306, A. Malcolm

Next!

Back to Castle Leoch. We can consider Rupert’s hearty beating of Jamie who gallantly choses fists over strap (enough straps) to protect loose-behaving Missy Laoghaire. Once again, mars are treated by Outlander Nurse. But, none of these blows caused permanent damage, so let’s move on!

Outlander ep 102, Castle leoch

4.  BJR Backlash:

Just right for Hallowe’en – foul work by a foul one! Fast forward to ep 106, The Garrison Commander, wherein Captain Blackguard informs Claire of his beautiful masterpiece. Produced four years earlier, BJ floged Jamie’s back into a bloody mess using a cat-‘o-nine tails with lead tips. Yep, these do leave scars!  And, dinna forget, Jamie already had been flogged days earlier! 😳

If you can stomach more flogging details, read Anatomy Lesson #10, Jamie’s Back – Aye, Jamie’s Back!

Described by Dougal in Outlander book: 

Dougal grimaced. “A pitiful sight, it was, too—still raw, no more than half-healed, wi’ the weals turned black and the rest yellow wi’ bruises. The thought of a whip comin’ down on that soreness was enough to make me blench, along wi’ most of those watching.”

Outlander ep 106, The Garrison Commander

So naturally, the back scars persist two decades later.

A splendid quote from Voyager book; Jamie’s scars have healed and contracted as scars normally do. 

I curled up behind him, knees fitting neatly behind his own. The firelight shone dully from behind me now, gleaming over the smooth round of his shoulder and dimly illuminating his back. I could see the faint lines of the scars that webbed his shoulders, thin streaks of silver on his flesh. At one time, I had known those scars so intimately, I could have traced them with my fingers, blindfolded. 

Footnote #3: To my eye, the prosthesis at Madam Jeanne’s establishment appears identical to the original. Over a 20-year span, such scars should contract and thickness diminish.  I suggest a new prosthesis to document these changes, an expected progression of wound healing and scar formation.

Outlander ep 306, A. Malcolm

5. MacDonald’s Sword Work:

Back to the early years. Ye ken the MacDonald clan with its three nasty-mouthed bros? Best ignore them, Jamie.

Nope. He gives them sass and in return, suffers a slice and dice Big Mac Attack! Three against one? No fair!

Outlander ep 110, By The Pricking of My Thumbs

The moral to this event is arguable, but consider something along the line of: dinna get mouthy with the MacDonald clan, especially if three well-armed laddies are against one!

But, Jamie exacts his revenge as he slices the hamstrings of one attacker, who from henceforth will hobble. And, who is cowering behind the tree? The cowardly Duke, who soon has a fate-date with The Godfather! Yes!!!

Outlander ep 110, By The Pricking of My Thumbs

Later, Claire stitches Jamie’s sword wound using the biggest needle she can find – royally POed!  Most of you ken that she accidentally stuck that needle into “Jamie’s” skin during filming. Och! 😱

Footnote #4: If you chose this as the only injury not in the books, score! Although Diana didn’t write the MacDonald fight, Jamie does suffer a saber-slash at Prestonpans. Here from Dragonfly in Amber:

It was a saber-slash, slanting across the ribs. A lucky angle; straight in and it would have gone deep into the intercostal muscles between the ribs. As it was, an eight-inch flap of skin gaped loose, red beginning to ooze beneath it again with the release of pressure. It would take a goodly number of stitches to repair, but aside from the constant danger of infection, the wound was in no way serious.

Outlander ep 110, By The Pricking of My Thumbs 

Did the Outlander FX team include the scar from the Sandringham kebby-lebby? Yep! There it is basking in Claire afterglow!

Outlander ep 306, A. Malcolm

6. BJR Smashing:

You ken about smashing pumpkins? BJR has his version, whacking Jamie’s hand with a mallet, smashing metacarpals and phalanges.  

Read more about BJR atrocious pastimes in Anatomy Lesson #22, Jamie’s Hand – Symbol of Sacrifice!

Outlander ep 115, Wentworth Prison

Once again, Claire to the rescue! She stitches Jamie’s wounds and splints broken metacarpals and phalanges. Herself clearly explains the fate of Jamie’s paw after BJR’s maniacal ministrations (Outlander book):

I began to lose myself in the concentration of the job, directing all my awareness to my fingertips, assessing each point of damage and deciding how best to draw the smashed bones back into alignment. Luckily the thumb had suffered least; only a simple fracture of the first joint. That would heal clean. The second knuckle on the fourth finger was completely gone; I felt only a pulpy grating of bone chips when I rolled it gently between my own thumb and forefinger, making Jamie groan. Nothing could be done about that, save splint the joint and hope for the best.

The compound fracture of the middle finger was the worst to contemplate. The finger would have to be pulled straight, drawing the protruding bone back through the torn flesh. I had seen this done before—under general anesthesia, with the guidance of X rays.

Outlander ep 116, To Ransom A Man’s soul

And, heroically repairs his mangled hand. Not a surgeon yet, but she did well!

Outlander ep 116, To Ransom A Man’s soul

Are Jamie’s finger scars visible after 20 years? Oh, indeed they are! Look closely; nothing shows them better than eating grapes.

FX peeps were on their game. Plain as the back of your hand. Not that Claire was paying much heed to those scars, mind ye. Snort!

Outlander ep 306, A. Malcolm

7. BJR Burn:

Oh, and among those grim hours in the hands of a mad man, let’s not forget the ghastly image of BJR directing Jamie to burn initials into the flesh overlying his heart. Randall offers a red hot wax stamp to “seal” the job! Gah!

Outlander ep 116, To Ransom A Man’s Soul

Those initials do not survive because TV Godfather excises them and casts  into the fiery pit. Go Murtagh! Rah! 

Footnote #5: In Outlander book, Sir Marcus removes the offending button of skin: 

“Best let me help ye, man. Ye’ll fall on it in a moment.” After a moment’s pause, Jamie reluctantly surrendered the knife and lay back against the wadded blanket. He touched his chest an inch or two below the nipple. “There.” 

Sir Marcus reached to the sideboard and snagged a lamp, setting it on the stool he had vacated. At this distance, I couldn’t see what he was peering at; it looked like a small red burn, roughly circular in shape. He took another deliberate pull at his whisky glass, then set it down next to the lamp and pressed the tip of the knife against Jamie’s chest. I must have made an involuntary movement, because the Lady Annabelle clutched my sleeve with a murmured caution. The knife point pressed in and twisted suddenly, flicking away in the motion one uses to cut a bad spot out of a ripe peach. Jamie grunted, once, and a thin stream of red ran down the slope of his belly to stain the blanket.

Talk about branding! Deeply grateful, today’s entrepreneurs never met Johnathan Wolverton!  

Outlander ep 116, To Ransom A Man’s Soul

Back at the brothel, the burn scar is on full display (red arrow), looking a bit like a supernumerary nipple! He, he. The Starz crew didna forget!

Outlander ep 306, A. Malcolm

And, finally, the last wound!

8. BJR Culloden Slash: 

Black Jack is at it again – fiendish fiend! At Culloden, Jamie glances away from a fallen Randall and swish, the blackguard’s blade strikes and bites verra close to Jamie’s femoral artery! 

Outlander ep 301, The Battle Joined

Twenty years later after the reunion-union, Claire espies the long thigh scar. Not quite as described in Voyager, but close. Outlander team snagged this one, too!

The scar ran from midthigh nearly to his groin, an eight-inch length of twisted, whitish tissue. I couldn’t repress a gasp at its appearance, and dropped to my knees beside him. I laid my cheek on his thigh, holding tight to his leg, as though I would keep him now—as I had not been able to keep him then. I could feel the slow, deep pulse of the blood through his femoral artery under my fingers—a bare inch away from the ugly gully of that twisting scar. 

….Soft as a moth flying in the dark, my hand skimmed his leg, and found the thin deep runnel of the scar. My fingers traced its invisible length and paused, with the barest of touches at its end, wordlessly asking, “How?”

His breathing changed with a sigh, and his hand lay over mine.

“Culloden,” he said, the whispered word an evocation of tragedy. Death. Futility. And the terrible parting that had taken me from him. 

Foot Note #6: In Voyager book, the scar extends to Jamie’s groin. The TV scar is closer to the knee – offering a modicum of modesty as millions take notice??? 😉

Outlander ep 306, A. Malcolm

So, eight wounds and FX folks nailed them all. Go team!

Think about it: BJ delivered almost 40% of Jamie’s wounds. However, if one counts each back scar, he owns well over 90% of Jamie’s mars and scars!

Oh, and here’s a wee bonus! Dinna forget loving Laoghaire’s contribution to Jamie’s landscape when the mad matron peppers him with bird shot. Of course, this event occurs after the reunion so those scars must await Season 4! Whew!  

Starz ep 308, First Wife

Let’s close with this lesson with a snippet from big book seven, An Echo in the Bone, which aptly describes Claire as Jamie’s healer and helpmeet. Not really a spoiler as it reveals no plot points.  So, safe to read.

A shadow fell across the floor in front of me and I looked up. Jamie was standing there with a most peculiar look on his face. 

“What?” I said, startled. “Has something happened?”

“No,” he said, and advancing into the study, leaned down and put his hands on the desk, bringing his face within a foot of mine.

“Have ye ever been in the slightest doubt that I need ye?” he demanded. It took roughly half a second of thought to answer this. “No,” I replied promptly. “To the best of my knowledge, you needed me urgently the moment I saw you. And I haven’t had reason to think you’ve got any more self-sufficient since. 

Outlander ep 308, First Wife

Final Points: Generally, society considers scars to be unwanted and unsightly. However, from anatomy and pathology POVs, scar formation is a normal process. Yes, indeed!  This is the way mammalian creatures typically repair tissue disruption –  like a biological bandaid. Although a scar may not perform as well as the original tissue, it keeps the body functional and responsive. To learn more about injury and repair, visit these anatomy lessons:

Recall the start of this lesson?

  • Were all scars accounted for? Yes.
  • Are any scars missing? No.
  • Were they accurately depicted? Mostly.
  • Did they change? Mostly.

Jamie’s mars and scars paint a poignant history. Claire was there for him from the get-go, treating broken bones, gunshot wounds, contusions, lacerations, incisions, dislocations, burns, and emotional abuse. Cheers to the gallant lass and her braw lad (and their creator)!

The deeply grateful,

Outlander Anatomist

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Photo Credits: Sony/Starz , adc.bmj.com (Image A); sghs.org (Image B)  

Fun Fact – Borborygmi

borborygmi

Learn more about borborygmi in Anatomy Lesson #16: Jamie’s Belly or Scottish Six-Pack!

And from Outlander book:

I wasn’t at all thirsty, but the faint scent of honey reminded me that I was starving, and had been for some time. My stomach gave an embarrassingly loud growl, protesting my neglect. “Hey, then, Jamie-lad! Hungry, are ye? Or have ye a set of bagpipes with ye?” shouted Rupert, mistaking the source of the noise. “Hungry enough to eat a set of pipes, I reckon,” called Jamie, gallantly assuming the blame. A moment later, a hand with a flask came around in front of me again. “Better have a wee nip,” he whispered to me. “It willna fill your belly, but it will make ye forget you’re hungry.”

See Jamie stave off Claire’s borborygmi in Outlander, Starz, episode 101: Sassenach!

The deeply grateful,

Outlander Anatomist

Anatomy Lesson #23: Harming Hands – Helping Hands – Healing Hands

Hallo Outlander Anatomy students! Welcome to Anatomy Lesson #23: The Hand – Part 2. Anatomy Lesson #22 introduced the hand but there is still much more structure and function to learn.

Today’s task is three-fold: to enrich our understanding of hand anatomy, to apply that anatomy using images from Starz episodes and to consider how hands are used. For most of us, our hands are with us throughout life so the way we use them helps define how we work, play and live (Photo A).

So, how do we use our hands? What tasks do we apply them to? Are the tasks helpful, harmful or neither? Outlander books and the Starz series provide abundant examples of hurtful hands, helpful hands and healing hands which are considered in this lesson. Just so we are all on the same page, all Starz images in this lesson are from episode 116, To Ransom a Man’s Soul, unless otherwise stated.

hands of love KLS edited

Photo A

Let’s begin the lesson with a brief review of digit and thumb movements and of the hand skeleton.

Our four fingers (U.S. definition or digits #2-#5) carry out four movements: abduction, adduction, flexion and extension (Photo B). Try all four movements with your own fingers.

finger movements KLS edited

Photo B

Because thumb anatomy differs from that of the fingers, it can perform seven independent movements: abduction, adduction, extension, flexion, opposition, reposition (Photo C) and circumduction (thumb moves in a circle – not shown in Photo C). Try all seven thumb movements.

Reposition (Photo C – right image) is the hand with all digits at rest or repose, a benign anatomical position maintained with little muscular effort.

thumb movements KLS edited

Photo C

In the image below, Claire’s healing hand is held in repose/reposition as she offers comfort to an angry, distraught guilt-ridden Jamie:

“Dinna touch me!” … “You canna save a man that doesna want saving!”

epi 116 good hand in repose KLS edited

Next, consider the crazy creepy crawler’s hand reaching for Jamie, the “object” of his obsession (Starz episode 115, Wentworth Prison). The palm is turned from our view but consider his hand. Is it at rest? Is it neutral? Anatomically, BJR’s hand yearning for Jamie is very nearly in reposition and although it may seem benign, we know it portends great harm. There’s a keen difference between anatomical positions of the hand and the intent behind such positions.

ep 115 BJR hand KLS edited

Next, let’s review bones of the hand (Anatomy Lesson #22). The complex skeleton of the hand contains 27 bones (Photo D – left hand, palm up): 8 carpals in the wrist, 5 metacarpals in the mid-hand and 14 phalanges in the digits. Each finger (digits #2-#5) contains three phalanges but the thumb (digit #1) has only two.

The bones of the hand create many joints (Photo D):

    • blue arrow shows wrist joints (between forearm and carpals)
    • orange arrow shows carpometacarpal joints (CM)
    • green arrow shows metacarpophalangeal joints (MP)
    • turquoise arrow shows proximal interphalangeal joints (PIP)
    • black arrow shows distal interphalangeal joints (DIP)
    • red arrow shows a single interphalangeal joint (IP) of thumb.

hand-bones-KLS-edited

Photo D: ©Stockmedicalart.com 2012

This creative rif on “The Scream” by Edvard Munch (Photo E) warns us that up next is toxic/nuclear waste in the form of handiwork by the bloody black-hearted bastard. In this lesson, I do resort to name calling – I canna help it when it comes to that wicked wretch!

hazard-symbol-munch-scream KLS edited

Photo E

Now for applied anatomy, first of the hand bones: the villainous Jack-Hammer mangled the bones of Jamie’s left hand (right hand in the book) such that Claire is tasked with treating nine fractures. From herself’s own words (Outlander book):

…”A single broken finger is enough to sink a strong man to his knees with nauseated pain…“I carefully picked up the smashed right hand, bringing it into the candlelight for examination. It would have to be set, and as soon as possible. The injured muscles were already clawing the fingers inward.

“It was a long, horrible, nerve-wracking job….. some parts, such as the splinting of the two fingers with simple fractures, went quite easily. Others did not…. I set his middle finger, exerting considerable force necessary to draw the ends of the splintered bone back through the skin.

The next image shows a compound or open fracture of the proximal phalange of Jamie’s middle finger. Compound fractures are characterized by broken bone(s) protruding through the skin and indeed the distal broken fragment is clearly visible (aqua arrow) as Claire rinses it with clean (sterile) water.

ep-116-compound-fracture-KLS-edited

Claire retracts the tip of Jamie’s finger pulling the bony fragment back into the finger. She then approximates the broken ends of the phalange. Retraction could require some effort because following a fracture, attached muscles undergo spasm to form a “natural splint” designed to keep the broken ends of a bone together as much as possible. This explains the quote from Outlander book:

“The injured muscles were already clawing the fingers inward.”

ep 116 compound fracture 01 KLS edited

And a final quote from Outlander book:

“All five fingers eventually lay straight as new pins, stiff as sticks in their bandaged splints… By good luck, only the one joint had been badly damaged…there was nothing I could do about the cracked metacarpal bones or the puncture wound.”

As Claire applies her skills to Jamie’s battered hand, she stitches the lacerations and places his hand on a small wooden pallet. She binds the badly damaged ring finger to the little finger using the latter as a split. All is then secured with a linen strip wound around a wooden peg that is then inserted into a hole in the wood pallet. Wow! This is so impressive and resourceful as no knots are require; the peg can be removed, the strip unwound and the wound attended without messing with knots. Overall, this ingenious device is an external cage which stabilizes the hand in the proper anatomical position and immobilizes it during the healing process. Brilliant!

Finally, did you ken the red, purple, and dusky blue bruises forming on Jamie’s hand? There is more about bruising later in this lesson.

ep 116 hand cage KLS edited

Now for applied anatomy of joints of the hand: in this jarring scene, we see the MP joints (green arrows) of BJR’s right fingers. He tells a traumatized Jamie “I know you can do better than this,” tapping the tip of his nose as one might correct an errant child. The total absence of regard for Jamie’s suffering tells us that the cunning cruel Captain does dwell in darkness and in darkness he shall remain.

ep-116-BJR-I-know-you-can-do-better-KLS-edited

Next, the unholy-one eyes Jamie writhing in agony: “Am I close? Have you reached your limit yet?” Oozing an air of utter boredom and sure knowledge of outcome, the mad menacing maniac sits with flexed left fingers that clearly display his left PIP joints (aqua arrows).

ep-116-BJR-have-you-had-enough-KLS-edited

Soon, BJR instructs Jamie to brand himself with BJ’s glowing wax seal stamp – over the left breast and near the heart. “Are you mine? Show me … do it!” The red arrow shows the flexed IP joint and the green arrow indicates the flexed MP joint of Randall’s right thumb. Remember: the thumb has only two phalanges with one IP joint shared between them.

ep-116-branding-Jamie-02-KLS-edited

Wracked with pain, Jamie brands himself but stubbornly sears his left side; his heart belongs to Claire! The flexed DIP joints (red arrows) are visible on Jamie’s right fingers as he grips the stamp.

ep-116-branding-Jamie-KLS-edited

Remember the anatomical mantra: the more bones in a body part, the more possible joints between the bones; the more joints, the more possible movements at the joints? Bone movements occur when muscles that attach to them undergo contraction. So, to better understand hand movements, we must next consider muscles operating the hands.

In Anatomy Lesson #22 we learned that some forearm muscles move bones of the hand. To review, the forearm is divided into two compartments. The anterior compartment contains eight muscles six of which attach to bones of the palmar (front) hand. The posterior compartment contains 12 muscles nine of which attach to bones of the dorsal (back) hand. Covering all the forearm muscles that move hand bones isn’t feasible in a single lesson, so let’s consider a few.

Three important muscles originate from the anterior forearm and end on bones of the digits; these are the long flexor tendons.

The first muscle is flexor digitorum superficialis or FDS (Latin meaning superficial flexor of digits); this muscle arises from humerus and radius (Photo F). Near the wrist FDS splits into four tendons, one to the intermediate phalange of each finger. Contraction of FDS mainly flexes PIP joints (Anatomy Lesson #22) but continued contraction flexes MP and wrist joints.

Try this: strongly flex (curl) your fingers and wrist joint. You used FDS to accomplish this. Identify wrist, MP and PIP joints. Flexion of these joints is critical for the grip (Anatomy Lesson #22).

Figure0426A FDS KLS edited

Photo F

Please think, if the digits have a superficial flexor will they also have a deep flexor? If you answered yes, then you are getting the idea of anatomy! The next anterior forearm muscle is flexor digitorum profundus or FDP (Latin meaning deep flexor of digits). Deep to FDS, FDP (Photo G) arises from the ulna and breaks into four tendons near the wrist to end on the distal phalange of each finger.

Now consider this: if tendons of FDS insert on the intermediate phalanges how will tendons of the deeper-lying FDP reach the distal phalanges? The body’s answer is ingenious! FDP goes through FDS: all four tendons of FDS split to allow FDP tendons to reach the distal phalanges (Photo G – red arrow). Do you see the splits? The engineering is awesome!

FDP flexes the DIP joints but it also contributes to flexion of PIP, MP and wrist joints.

Try this: Attempt to flex only the DIP joints of your fingers. Can you do it? I know a few folks who can but it is unusual. DIP joints typically flex in conjunction with PIP joints.

Figure0426B-FDP-KLS-edited

Photo G

The third muscle of the anterior forearm is Flexor Pollicis Longus or FPL (Latin meaning long flexor of thumb). FPL originates from the radius and inserts on the distal phalange of digit #1, the thumb (Photo H). Its major action is to flex the IP joint of the thumb but continued contraction also helps flex the MP joint.

Try this: flex your thumb and find the IP joint. Flexion is caused by FPL.

Figure0426B FPL KLS edited

Photo H

Do you recall those eight carpal bones arranged in two rows of four bones each (Anatomy Lesson #22) – aye, the ones with the funny mnemonic? These bridge the gap between radius and ulna and five metacarpals. More than a dozen strong fibrous wrist ligaments bind together carpals, metacarpals, radius and ulna (Photo I –  grey strands).

Figure0437B carpal arch KLS edited

Photo I

Two-dimensional images imply that the carpals lay in a flat plane, but this is not so. Wrist ligaments secure them into a curved carpal arch that is convex on the dorsum and concave on the palmar surface (Photo J – curved red line). The carpal arch is spanned by a fibrous sheet, the flexor retinaculum thus forming a potential space, the carpal tunnel (Photo J). But, the tunnel is NOT empty because it contains four FDS tendons, four FDP tendons, one FPL tendon and the median nerve (Anatomy Lesson #22).

Now for an important clinical correlation: truly a tight squeeze, any swelling of structures within the carpal tunnel compresses the median nerve and affects hand areas it subserves, a condition known as carpal tunnel syndrome. Symptoms may include tingling, numbness and pain with reduced strength of thumb and index, middle and half the ring fingers. Repetitive motions that over-extend the wrist such as keyboard use, piano playing, or prolonged use of vibrating tools may be contributing factors.

Figure0444B-Carpal-tunnel-KLS-edited

Photo J

Next, we consider the muscles of the back of forearm and hand: known as long extensor tendons, several muscles reach from posterior forearm to bones of the hand. We won’t name these but to summarize: three long tendons extend the wrist (Photo K – blue arrows) and 5+ long tendons extend the finger joints (Photo K – red arrows). Three long tendons extend and/or abduct the thumb (Photo K – black arrows). Whew!

Figure0424A-long-extensor-tendons-KLS-edited

Photo K

A closer view at the dorsal hand shows long extensor tendons as they cross the wrist. These tendons are held in check by a fibrous band, the extensor retinaculum (Photo L – black arrow). Note bands of fibrous tissue between the long extensor tendons. Known as intertendinous connections they augment extension of the fingers as a unit; if one extensor muscle contracts, it helps activate its neighbors (Photo L).

Try this: Intertendinous connections are quite variable but let’s try to locate one. Place forearm and hand flat on a surface. Pronate the forearm to expose the back of your hand. Try to lift (extend) just the little finger. Can you do it? Next, lift ring, middle and index fingers one at a time. Are some fingers harder to lift independently? I have greatest difficulty lifting middle and ring fingers independently so I know they are bound by an intertendinous connection. Try to locate one of yours.

Figure0453A-Extensor-tendons-KLS-edited_1

Photo L

Now, let’s consider intrinsic muscles of the hand beginning with the palmar surface. Palmar skin is tightly bound to an underlying fibrous sheet, the palmar aponeurosis, a feature that aids grasping (Photo M – red arrow). Two superficial muscles are apparent: palmaris longus and palmaris brevis. A forearm muscle, the tendon of palmaris longus blends with the palmar aponeurosis and tenses it during contraction. Many anatomists regard palmaris longus to be a vestigial muscle because it is absent in about 14% of people and its absence doesn’t really affect our ability to grip. Palmaris brevis is a tiny postage stamp-sized muscle near the base of the little finger (Photo M); its contraction puckers the palm skin and deepens a cupped palm.

Figure0442A-palmaris-longus-&-brevis

Photo M

Try this: Spread your digits and tap your palm. Feel that taut springy tissue? That’s the palmar aponeurosis. Now, bring pads of thumb and little finger together and strongly flex the wrist. Does a tendon stand out in the midline (Photo N – black arrow)? If so, this is palmaris longus. Repeat with the opposite side. What is the pattern of your forearm? Do you have two palmaris longus muscles, one or neither? Turns out I have one on the left but none on the right.

Palmaris longus KLS edited

Photo N

I love watching Jamie balance and twirl a dirk on the palm of his hand (Starz episode 105, Rent). See the puckered flesh at the base of his palm (red arrow)? This is caused by contraction of palmaris brevis to help cup his palm and support the dirk. Yep, Jamie has one! Is Claire watching his clever performance? Aren’t we all?

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The hand contains 19 intrinsic muscles (including palmaris brevis), meaning they arise and insert within the hand itself. These small muscles initiate fine movements of the digits. It would be tedious to name them all so understand that the thumb has four intrinsic muscles concerned with flexion, opposition, adduction and abduction (Photo O – green overlay). The little finger has three muscles which flex, oppose, and abduct (Photo O- purple overlay). Between the long flexor tendons and metacarpal bones are 11 additional muscles (lumbricals and interossei) which help flex, abduct and adduct the fingers (Photo O – black arrows). All totaled a whopping 34 forearm and hand muscles are involved in hand movements!

Figure0443B-intrinsic-hand-muscles-KLS-edited

Photo O

Like most body parts, the hand needs a blood supply. The large ulnar and radial arteries descend through the forearm, cross the wrist to form superficial and deep palmar arches (Photo P). Branches from both arterial arches produce two small arteries (proper palmar digital arteries) for each finger. The radial artery supplies branches to the thumb. The dorsal hand (not shown) has a smaller arterial arch that produces two more small arteries to each finger. Ergo, each finger has four supplying arteries; the thumb has three.

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Photo P

For those who do not understand blood flow, a full lesson on this subject lies in the future. For now, please know that the digital arteries carry blood ladened with oxygen and nutrients to the digits. They divide into smaller arterioles which branch into microscopic capillaries forming capillary beds (Photo Q). In the capillary bed, oxygen and nutrients are exchanged for carbon dioxide and waste products. The capillary bed reforms into venules that unite to form veins draining blood from the tissues. This general plan is followed throughout the hand and in most body tissues.

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Photo Q

Time for a clinical correlation about blood supply: capillaries have very thin walls. When subjected to trauma, these vessels burst leaking blood into surrounding soft tissues. Extravasated blood presents as a contusion, a reddish-purple-dusky discoloration which doesn’t blanch when pressed: the classic “black and blue” bruise (Photo R).

Bruising KLS edited

Photo R

Several students have inquired about Jamie’s blackened hand and digits following his rescue from Wentworth Prison. They were concerned that his hand exhibited tissue necrosis or gangrene. But no, discoloration is due to the beating administered by that depraved, demented devil. This gut-wrenching scene gives evidence of early bruising (black arrow): a vivid color range from deep red to purple to dusky blue. Very convincing!

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Later on the Cristabel, Jamie’s thumb and fingertips are fully black and blue. The pounding mallet did a number on his hand capillaries and the bruising is fierce!

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We are done with the real and applied anatomy lesson so let’s finish with examples of how hands are used in Starz episode 116 To Ransom a Man’s Soul.

“Dear God, you are a magnificent creature” utters the crazy cunning cutthroat with Jamie spread across his lap. As I gazed at this imagery, it seemed vaguely familiar. Then, B-I-N-G-O!

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Intentional or not the position, posture and attitude are very nearly a mirror image of the Pietà, a Renaissance sculpture by Michelangelo Buonarroti (1475-1564) of the Madonna cradling a crucified Christ. This riveting juxtaposition of images reveals universal opposites: dark versus light; evil versus good; cruelty versus mercy, all deeply rooted themes in Diana’s works. Randall even draws the analogy to Jamie’s suffering: “Ah, so that’s your plan; to submit like Christ on the cross?” Helping hands, healing hands, or hurting hands. No brainer, here!

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Later, the foul, festering fiend sensuously rubs lavender oil into Jamie’s painful burn telling him “These are Claire’s hands. Think of your wife.” There are new bruises on Jamie’s left shoulder. We don’t know what caused these – mayhap a mallet blow went astray? We shouldna be deceived by this perceived gentleness because BJ is about to deliver extreme mental pain to Jamie. Hurting hands, helping hands, healing hands?

ep 116 BJR these are Claire's hands KLS edited

After suffering hours of agonizing pain, BJ tells Jamie to:

“Think of Claire. Think of your wife. Wait for me. Claire’s here.”

Sadly, the soulless one said he would have Jamie’s surrender before he left this world and he does. Then BJ delivers his cruel, mocking coup de grâce: “I understand. How could she ever forgive you?” His hands are made for hurting and they are remarkably skilled at their work!

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Ugh! Enough of hurting hands…How about some healing hands? We already witnessed Claire’s healing hands as she cleanses and sets Jamie’s battered hand. Here she tidily stitches his skin lacerations. Her competency as a 20th century WWII combat nurse, her ingenuity at using 18th century tools and her brilliant, fertile mind are testimonies of her love and devotion to Jamie. Her hands have come to his rescue over and over throughout the Starz series; a true symbol of healing.

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We’ve seen Claire reset Jamie’s broken bones and mend his wounds. Picking lavender, grinding buds in a mortar and pestle to make oil of lavender is yet another example of her healing hands as she prepares to enter the darkness with Jamie.

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As she rests her healing hand on her husband, he struggles with shame and self-loathing. “You belong to no one else but me…Well, Randall had your body but I’ll be damned if he has your soul as well.” Go Claire! Ye make us proud!

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Finally, Godfather Murtagh’s healing hands are at work as he cuts JR from Jamie’s skin and casts the scrap into the fiery furnace! Mercifully, healing hands are plentiful in Starz episode 116.

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Let’s finish this lesson with examples of helping hands. First is a fantastic image of the three Highland musketeers rescuing Jamie from the “thug under the door.” Murtagh stolidly carries his precious cargo from Wentworth Prison to freedom. Angus furtively peers backward with dirk in hand while Rupert rides shotgun! Yeah, helping hands! Ye made me weep with relief!

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So many helping hands at the monastery reach out to the party of Highlanders offering refuge, supplies and care for Jamie, wounded in body and soul.

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More helping hands as the goodly Father comforts Claire after her confession: a far cry from Father Bain, no?

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Finally, we catch Angus’ au revoir kiss but did ye ken that the wee laddie’s helping hand helps itself to some of Claire’s personal real estate? Naughty Angus Mhor!

ep 116 Angus & Claire KLS edited

Helping hands, healing hands, hurting hands… how shall we use our own? Mine will continue to write lessons throughout the summer although most will be shorter and less complex. Thanks to all who love anatomy and Outlander!

Oh! Last week, I was invited by Jennifer Barnes, Ryan Hooks and Keetin Marchi (they are such great fun!) to give a mini anatomy lesson about the hand on the Outlander Aftershow at TheStream.TV. You can see it below around 16:30. Now that we face another bout of withoutlander, you can join our friendly hosts for the Outlander Book Club on Monday nights where they compare and contrast the book and the show: http://bit.ly/1dqHXxQ. Happy Summer!

The deeply grateful,

Outlander Anatomist

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Photo creds: Sony/Starz, Netter’s Atlas of Human Anatomy, 4th ed Gray’s Atlas of Anatomy for Students, 2005, ClinicallyOriented Anatomy 5th ed, www.artsology.com, www.imgbuddy.com, www.medicalartlibrary.com, www.parlmreadingperspectives.wordpress.com, www.wikipedia.org, www.wikiradiography.com, www.shutterstock.com