palmar spaces

PALMAR SPACES

The PALM

20 Intrinsic muscles9 Flexor tendonsUlnar & Median Nerves.Palmar arterial arches

Wrapped in Fascial layers

FOUR COMPARTMENTS

THENAR

HYPOTHENAR

INTERMEDIATE

ADDUCTOR

THENAR• Abductor Pollicis Brevis• Flexor Pollicis Brevis• Opponens Pollicis

HYPOTHENAR• Abductor Digiti Minimi• Flexor Digiti Minimi• Opponens Digiti Minimi

INTERMEDIATE• Flexor tendons covered by Synovial sheaths• lumbricals• Palmar arterial arches• Branches of Median and Ulnar nerves

ADDUCTOR• Adductor Pollicis

• No well defined spaces inside the fascial compartments

• Become apparent when there is collection of pus

• Mid palmar septum/Intermediate palmar septum divide intermediate comp into Thenar & Mid palmar spaces

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Palmar Spaces MidPalmar space Thenar space Hypothenar space Radial Bursa Ulnar bursa Interdigital Web spaces Pulp spaces Forearm space of Parona Dorsal Sub aponeurotic space

Midpalmar space• Anterior – Palmar aponeurosis,

superficial palmar arch, flexor tendons of medial 3 digits covered in ulnar bursa and medial 3 lumbricals

• Posterior - Fascia covering 3rd & 4th interossei and metacarpal bones

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

Thenar Space• Anterior - Palmar aponeurosis,

superficial palmar arch, flexor tendon of index finger covered with synovial sheath, tendon of FPL

• Posterior – fascia covering adductor pollicis• Lateral - Lateral palmar septum• Medial MidPalmar septum.• Proximal – distal margin of flexor retinaculum• Distal - 1st web space thru lumbrical canal

Hypothenar Space

• Posterior – 5th Metacarpal

• Lateral – Hypothenar septum

• Medial & Ant– Hypothenar Muscles

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Radial Bursa

• Synovial sheath surrounding Flexor Pollicis Longus tendon

• Extends from forearm( 2 cm prox to Flexor retinaculum) to base of terminal phalanx of thumb

Ulnar Bursa• Common synovial sheath surrounding

tendons of Flexor digitorum superficialis and profundus

• Extends from forearm( 2 cm prox to Flexor retinaculum) to mid palm level where it ends as cul-de-sac .

• Continuous with digital sheath around flexor tendons of little finger

Web Spaces• 4 Subcutaneous spaces

• From its free margin – extends to level of MCP joint.

• CONTENTS - S/C fatSuperficial transverse metacarpal ligament, interosseous and lumbrical tendons, digital nerves and vessels.

• Inflammation of synovial sheath

• Little finger – infects Ulnar bursa• Thumb – infects Radial bursa• Horse Shoe abscess

• Can extend to MidPalmar and Thenar spaces (Pus tanks)

• Through lumbricals to Web spaces (Pus taps)

Flexor Tenosynovitis

Kanavel’s Cardinal SignsKanavel’s Cardinal Signs• finger in slight flexionfinger in slight flexion• fusiform swellingfusiform swelling• pain with extension.pain with extension.• tenderness along tenderness along

tendon sheathtendon sheath

Thenar space inf• Swelling of thenar area• Thumb abducted & extended• Index finger flexed.

Midpalmar space inf• Dorsal swelling- inflated rubber glove• Inability to move long & ring fingers- pain

Web space inf

• Collar button abscess due to hour glass configuration

• Begins beneath palmar callus – in labourers• Incisions – 1 dorsal and 1 palmar.• Web - not incised

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.

Contents• Subcutaneous fatty tissue• Loculated by tough fibrous septa -

Extending from skin to phalanx.• Sensory nerves• Digital artery• ABSCESS – Whitlow/Felon• Complication - AVN of distal 4/5th of

phalanx (thrombosis of diaphyseal br of digital artery

Felon

FOREARM 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• Lateral – FPL• Medial - FCU• Infections - Incision either side of lower 3rd

of forearm

Management of Infection

Incise, Incise, Culture, Culture, Irrigate, Irrigate, Antibiotics,Antibiotics,Soaks,Soaks,ROM,ROM,Resting SplintResting Splint

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