Group 4 : The spaces of the hand and its applied anatomy

Group member:DhinagarKosillaEng Xin Yie

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 2nd, 3rd

and 4th finger. The ulnar bursa The radial bursa The midpalmar space The thenar space

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

The superficial pulp spaces of the finger.

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

Infection in pulp space

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.

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)

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.

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.

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.

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

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)

Ulnar and radial bursa

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.

Radial BursaRadial 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.

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.

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.

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 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.

Ulnar BursaUlnar 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.

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.

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..

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. 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.

•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

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

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.

Thenar space

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.)

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.

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.

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.

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

Deep fascial space infection Causes of the infection are:

Direct penetrating trauma Contiguous spread Hematogenous spread

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 2nd digit with rupture proximally.

•Thumb is held abducted and flexed.

Clinical

Treatment

Antibiotics

Incision along thenar crease (be warry of recurrent median nerve)

Dorsal longitudinal incion at web space to enter 1st web sapce

Mid Palmar infection

Closed space infection of the palmar space.

Clinical

•Loss of normal hand concavity.

•Tenderness of central palm.

•Pain with movement of 3rd and 4th digits.

•Can be from tenosynovitis of digits 3,4,5

Treatment

antibiotics

Surgery. Blunt dissection through palmar fascia on either side of D3 flexors