4. spaces of the hand & its applied anatomy[1]

1. Group 4 :
The spaces of the hand and its
applied anatomy
Group member:
Dhinagar
Kosilla
Eng Xin Yie

2. The spaces of hand are of pratical significance
because they may become infected and in
consequence become distended with pus. The
important spaces are:
The superficial pulp spaces of the finger.
The synovial tendon sheaths of the 2
nd,
3
rd
and 4
th

finger.
The ulnar bursa
The radial bursa
The midpalmar space
The thenar space

3. Superficial Pulp Space
The pulp space of the fingers is a closed fascial
compartment situated in front of the terminal
phalanx of each finger
Each space is subdivided into numerous smaller
compartments by fibrous septa
Infection of such a space is common and serious
Commonly occurring in the thumb and index finger
Bacteria are usually introduced into the space by
pinpricks or sewing needles

4. The superficial pulp spaces of the
finger.

5. Accumulation of inflammatory exudate within these
compartment causes the pressure in the pulp space
to quickly rise.
In children, pressure on the blood vessels could
result in necrosis of diaphysis
The close relationship of the proximal end of the
pulp space to the digital synovial sheath accounts
for the involvement of the sheath in the infectious
process when the pulp-space infection has been
neglected

7. Infection in pulp space

8. Felon
Felons are closed-space infections of the fingertip pulp usually
with staphylococci and streptococci.
The most common site is the distal pulp, which may be
involved centrally, laterally, or apically.
The septa between pulp spaces ordinarily limit the spread of
infection, resulting in an abscess, which creates pressure and
necrosis of adjacent tissues.
The underlying bone, joint, or flexor tendons may become
infected.
 There is intense throbbing pain and a swollen, warm,
extremely tender pulp.
Treatment involves prompt incision and drainage and oral
antibiotic therapy.

9. Whitlow
Whitlow is an infection of the pulp space of
the finger, usually caused by herpes simplex
type I virus (usually refer to herpetic whitlow)

10. Synovial tendon sheath

11. The common synovial sheath for the flexor tendons is
a synovial sheath in the carpal tunnel.
It contains tendons of the flexor digitorum superficialis
and the flexor digitorum profundus, but not the flexor
pollicis longus.
The sheath which surrounds the Flexores digitorum
extends downward about half-way along the
metacarpal bones, where it ends in blind diverticula
around the tendons to the index, middle, and ring
fingers. It is prolonged on the tendons to the little finger
and usually communicates with the mucous sheath of
these tendons.

13. Tenosynovitis
Tenosynovitis is the inflammation of the
fluid-filled sheath (called the synovium) that
surrounds a tendon.
Symptoms of tenosynovitis include pain,
swelling and difficulty moving the particular
joint where the inflammation occurs.

16. Trigger Finger
When the condition causes the finger to "stick" in a
flexed position, this is called "stenosing" tenosynovitis,
commonly known as "Trigger Finger."

17. Untreated infection of the synovial sheaths
can impair hand function
infection of the synovial sheaths of the
thumb or little finger may spread readily
into the palm and even into the
forearm(space of parona)

18. Ulnar and radial
bursa

19. The common and pollical sheaths are frequently
referred to in clinical writing as the ulnar and
radial bursae, respectively.
These two sheaths project proximally a short
distance above the flexor retinaculum, and they
usually communicate with each other in the
carpal tunnel.
Hence infection of the synovial sheaths of the
thumb or little finger may spread readily into the
palm and even into the forearm.

20. RadialBursa

RadialBursa

22. The synovial sheath of the tendon of flexor
pollicis longus (radial bursa).
This sheath is usually separate but may be
communicate with the common sheath behind
the retinaculum.
Superiorly, it is coextensive with the common
sheath and inferiorly it extends up to the distal
phalanx of the thumb.
Flexor pollicis longus tendon has itz own
synovial sheath that passes into the thumb.

23. This sheath allow the long tendons to move
smoothly.
Synovial sheath of the flexor pollicis longus
(radial bursa) – communicate with (ulnar
bursa) at the level of wrist in about 50% of
subj.

24. Infection Of Radial

Infection Of Radial
BursaBursaA patient's radial bursa is a continuation of the
tendon sheath of his flexor pollicis longus, so that
any infection inevitably involves both of them.
The distal phalanx of his thumb is flexed and rigid.
He cannot extend it, although he can extend his
other fingers normally. His hand is tender over the
sheath of flexor pollicis longus, and you may be able
to feel a swelling above his flexor retinaculum. If
treatment is delayed, infection may spread to his
ulnar bursa, or the tendon of his flexor pollicis
longus may slough.

25. UlnarBursa

UlnarBursa

27. Common flexor synovial sheath (ulnar bursa).
The long flexor tendons of the fingers (flexor
digitorum superficialis and profundus), are enclosed
in a common synovial sheath while passing deep to
the flexor retinaculum.
The sheath has a parietal layer lining the walls of the
carpal tunnel, and a visceral layer closely applied to
the tendons.
From the arrangement of the sheath it appears that
the synovial sac has been invaginated by the
tendons from its lateral side.

28. In hands, the tendons of the flexor digitorum
superficialis & profundus muscle invaginate a
common synovial sheath from the lateral
side.
Medial part, common sheath extends distally
on the tendons of little finger.
Lateral part, it stops on the middle of palm.
Distal ends of index, middle & ring finger
aquire digital sinovial sheaths..

29. Infection Of Ulnar

Infection Of Ulnar
BursaBursaInfection of the ulnar bursa is the most serious hand
infection, because it contains all the flexor tendons
of a patient's fingers. His whole hand is
oedematous, his palm is moderately swollen, and
there may a fullness immediately above his flexor
retinaculum. His flexed fingers resist extension,
particularly his little one, and least of all his index.
The radial and ulnar bursa sometimes communicate
with one another. So if one of them has been
infected, infection may follow in the other a day or
two later.

30. •Contains: tendons of flexor pollicis longus,
flexor digitorum superficialis and profundus to
index finger, palmar digital nerves and vessels
to thumb and radial side of index finger.
•Communicates: web of thumb and under
flexor retinaculum

31. Location
The thenar space lies posterior to the long flexor
tendons to the index finger and in front of the
adductor pollicis muscle.
Boundaries
•Radial: thenar eminence, radial bursa
•Ulnar: Middle metacarpal, ulnar bursa
•Superficial: Carpal tunnel
•Deep: Adductor pollicis

32. Clinical Significance
The thenar space lies just superficial to the adductor
pollicis muscle, forming a plane connecting the
deep aspects of the radial bursa and the ulnar bursa.
Abscess or space occupying lesions may spread
transversely through the thenar space deep in the
palm between the thumb and the carpal tunnel.

33. Thenar space

34. The thenar space is shown as
purple in the diagrams here. In the
cross section, the midpalmar space
is blue, the radial bursa is light blue
and the ulnar bursa is red.)

35. Mid Palmar Space
(Mid Central Palmar Space)
Contains: 3-5 flexor tendons, 2-4 lumbricals,
superficial palmar arch, 3-5 digital vessels and
nerves.
Communicates: subcutaneous tissues at webs
and extends dorsal to common flexor sheaths.

36. Location
The midpalmar space lies posterior to the long
flexor tendons to the middle, ring and little fingers.
It lies in front of the interossei and the 3rd, 4th and
5th metacarpal bone.

37. Boundaries
Anterior: flexor tendons of med 3 fingers
surrounded by synovial sheaths (ulnar bursa).
Posterior: 3,4,5, metacarpal bones with its
interossei muscles.
Medial: Hypothenar muscles.
Lateral: septum separating it from thenar space.
Distally: communicate with web spaces.
Proximally: Communicate with Parona space.

39. Deep fascial space
infection
Palm is relatively fixed…the dorsum will show
the infection.
4 potential spaces
Dorsal subaponeurotic space
Subfacial web space
Thenar space
Midpalmar space

41. Deep fascial space
infection
Causes of the infection are:
Direct penetrating trauma
Contiguous spread
Hematogenous spread

42. Thenar space infection
Closed space infection of the thenar space.
•Pain and swelling of thenar eminence and first web
space.
•Can be from tenosynovitis of 2
nd
digit with rupture
proximally.
•Thumb is held abducted and flexed.
Clinical

43. Treatment
Antibiotics
Incision along thenar crease (be warry of recurrent
median nerve)
Dorsal longitudinal incion at web space to enter
1st web sapce

44. Mid Palmar infection
Closed space infection of the palmar space.
Clinical
•Loss of normal hand concavity.
•Tenderness of central palm.
•Pain with movement of 3
rd
and 4
th
digits.
•Can be from tenosynovitis of digits 3,4,5

45. Treatment
antibiotics
Surgery. Blunt dissection through palmar fascia on
either side of D3 flexors