Palmar spaces - Types / contents

This slide gives you information regarding the Types of Palmar spaces, their contents & boundaries. Also certain aspects of Applied anatomy has been enlightened in the interest of Integrated teaching.

1. PALMAR SPACES
Dr.U. Murali. M.S;M.B.A.
Prof. of Surgery
D Y Patil Medical College
Mauritius

2. Objectives
Types of Spaces
Location & Boundaries
Contents
Applied Anatomy

3. PALMAR SPACES
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

4. Other Spaces
Web spaces
Space of Parona

5. Sup. Pulp space Sup. Pulp space

6. Superficial Pulp Space
Subcutaneous space
between distal phalanx and
skin of terminal digit.
Proximally – closed
anteriorly by fusion of
fibrous flexor sheath to
skin of digit at distal crease
Posteriorly fusion of deep
fascia to periosteum of
terminal phalanx

7. Contents
Subcutaneous fatty
tissue
Loculated by tough
fibrous septa -
extending from skin to
phalanx.
Sensory nerves
Digital Artery

8. Applied Anatomy
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

9. Felon

10. 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 )

11. Synovial Tendon Synovial Tendon
Sheath Sheath

12. Synovial tendon sheath
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.

13. The sheath which
surrounds the Flexor
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.

15. Tenosynovitis
It 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. Flexor Tenosynovitis
•Finger in slight flexionFinger in slight flexion
•Fusiform swellingFusiform swelling
•Pain with extension.Pain with extension.
•Tenderness along Tenderness along
tendon sheathtendon sheath

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

18. Ulnar & Radial Ulnar & Radial
Bursa 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. Radial BursaRadial Bursa

21. Radial Bursa
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.

22. Radial Bursa
Superiorly, it is
coextensive with the
common sheath and
inferiorly it extends up
to the distal phalanx of
the thumb.
Radial bursa –
communicate with
ulnar bursa at the level
of wrist in about 50%
of subj.

23. Infection Of Radial BursaInfection Of Radial Bursa
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 the thumb is flexed and rigid.
Pt cannot extend it, although can extend other
fingers normally. The hand is tender over the sheath
of flexor pollicis longus, and you may be able to feel
a swelling above the flexor retinaculum. If
treatment is delayed, infection may spread to the
ulnar bursa, or the tendon of flexor pollicis longus
may slough.

24. Ulnar BursaUlnar Bursa

25. Ulnar Bursa
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.

26. Ulnar Bursa
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.

27. Ulnar Bursa
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
acquire digital synovial
sheaths..

28. Infection Of Ulnar BursaInfection Of Ulnar Bursa
Infection of the ulnar bursa is the most serious hand
infection, because it contains all the flexor tendons
of a patient's fingers. Pt’s whole hand is
oedematous, the palm is moderately swollen, and
there may be fullness immediately above the flexor
retinaculum. The flexed fingers resist extension,
particularly the little one, and least of all is the 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.

29. Thenar space Thenar space

30. Thenar Space - Location
The Thenar space lies
posterior to the long
flexor tendons to the
index finger and in
front of the adductor
pollicis muscle.

31. Boundaries
Anterior - Palmar
aponeurosis / superficial
palmar arch, flexor
tendon of index finger
covered with synovial
sheath / tendon of FPL
Posterior – fascia
covering adductor
pollicis

32. Boundaries
Lateral - Lateral
palmar septum
Medial - MidPalmar
septum
Proximal – distal
margin of flexor
retinaculum
Distal - 1
st
web space
thru lumbrical canal

33. Thenar Space
(Lateral Central Palmar Space )
•Contains: Tendons of
FPL / FDS&P to index
finger, palmar digital
nerves and vessels to
thumb and radial side
of index finger.
•Communicates: web of
thumb and under
flexor retinaculum

34. 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.

36. 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.

37. Mid – Palmar Mid – Palmar
space space

38. 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.

39. Boundaries
Anterior – Palmar
aponeurosis / superficial
palmar arch, flexor
tendons of medial 3 digits
covered in ulnar bursa and
medial 3 lumbricals
Posterior - Fascia covering
3
rd
& 4
th
interossei and
metacarpal bones

40. Boundaries
Medial – Medial Palmar
septum
Lateral - Midpalmar
septum
Proximal – distal
margin of flexor
retinaculum
Distal - medial 2 web
spaces thru lumbrical
canals

41. 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.

42. Mid Palmar infection
Closed space infection
of the palmar space.
•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

44. Other spaces Other spaces

45. Web Spaces
4 Subcutaneous spaces
From its free margin –
extends to level of MCP
joint.
Contents - S/C fat
Superficial transverse
metacarpal ligament,
interosseous and
lumbrical tendons,
digital nerves and
vessels.

46. Interdigital Infection
Collar button abscess
due to hour glass
configuration
Begins beneath palmar
callus – in labourers
Incisions – 1 dorsal and
1 palmar.
Web - not incised

47. Space of Parona
Located in forearm
Continuous with
palmar space through
flexor tendons through
carpal tunnel
Anterior boundary -
flexor tendons covered
with tendon sheath
Posterior boundary -
Pronator quadratus