HAND SPACES ANATOMY & INFECTIONS

G.NARENDRA TEJANri medical college

Under guidance of dr.v.tatha rao ms

• Hand is covered by thick skin on palmar side- to withstand trauma

• Palmar skin adherent to palmar aponeurosis

• Underneath aponeurosis long flexor tendons pass into fingers through palmar arch

• This forms spaces in hand which can be potential areas of infections

• Hand spaces• Finger

– pulpspace– Proximal & distal volar space

• Palm– Web space– Mid palmar space– Thenar space

• Fore arm– Space of parona– Dorsum– Subcutaneous space– Sub aponeurotic space

Nail fold infection

• Paronychial/eponychial infections• Most common infection in hand• Cause- trivial trauma• Infection starts beneath

eponychyium & tracks around nail fold & nail

• Treatment – lift nail fold & inscision & drainage

Pulp space infection ( felon)• Situated between thick palmar skin &

terminal phalanx • Divided by multiple septa from skin to

phalanx• These loculi are occupied by fibro fatty tissue• Distal 4/5th of phalanx is supplied by

branches from digital arteries passing through septae

• If pus collects in this space ,tension increases,leading to occlusion of arteries

• Leads to ischemia of phalanx --- osteomyelitis

• Clinical features• Severe throbbing pain in

pulpspace ,aggravated by dependent position

• o/e – tense ,tender ,indurated pulp space

• Rx –incision over point of maximal tenderness

• If osteomyelitis –excision of bone

Web space infecton

• Spaces filled with areolar tissue between slips of palmar aponeurosis at bases of fingers in between them

Clinical features-• Swollen base of finger with seperation

of fingers• Rx transverse inscision over web space • Counter incision on dorsal side if spread

to posteriorly

MID PALMAR SPACE INFECTION• Lies under inner half of hollow of hand

between thenar & hypothenar eminences• Shape- triangular

Boundaries• Anteriorly- 3,4 flexor tendon sheaths ,3,4

lumbricals• Posteriorly- metacarpal bones with interossei• Radial side-fibrous tissue over thenar space• Ulnar side- fibrous tissue over hypotenar space

• Proximal- transverse carpal ligament• sometimes may extend

into fore arm space along flexor tendons

• Treatment- drainage of pus by incisions in ¾ 0r 4/5 digits & opening lumbrical sheath

• Clinical features• Pain & tenderness in palm• Edema on dorsum of hand• Loss of concavity of palm• Painful metacarophalangeal joint

movement• Fever• Palpable axillary lymph nodes• Collar stud abscess

complications

• Osteomyelitis• Osteoartritis• Stiffness of hand

Thenar space

• Lies under outer half of hollow of palm• Triangular in shape• Anteriorly- short muscles of thumb,flexors of

index finger,1,2 lumbricals• Posteriorly- adductor pollicis• Radially- radial bursa• Ulnar -septum between thenar & midpalmar • Distal –proximal transverse palmar crease• Proximal –transverse carpal ligament

Fore arm space

• Space of parona• Space in between flexor tendons &

pronator quadratus ,interosseous membrane

• Boundaries• Anterior- flexor digitorum profundus

with its synovial sheath• - flexor pollicis longus in its

synovial sheath

• Posterior-pronator quadratus,interosseous membrane

• Distal- reaches level of wrist• Proximal- continuous

withintermuscular spaces of fore arm• Cause- spread of infection from ulnar

/radial bursa

Clinical features ..• Swelling in front of wrist or lower fore

arm• Treatment • Incisions & drainage at lateral/medial

borders of forearm

Dorsal spaces

• Areolar tissue is much looser than in palm

• Divided into dorsal subcutaneous & dorsal sub aponeurotic spaces

• Both are triangular shaped with apex at wrist & base at knucles

• Dorsal surface recieves most of the lymphatic drainage of hand,including that from palmar surface

• Hence,even in palmar infections edema occurs on dorsal surface

patholophysiology

• Local features of inflammation stage of cellulitis• - severe pain throbbing,aggravated in

dependent positionStage of abscess/ brawny induration• - do not manifest early because of thick

overlying fascia & skin• Dx by triad of

swelling ,induration,localised tenderness

• All infections of hand are associated with dorsal reactionary edema

• Lymphadenopathy• General features – fever ,malaise,

tachycardia

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