PALMAR SPACES

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

Objectives

Types of Spaces

Location & Boundaries

Contents

Applied Anatomy

PALMAR SPACES

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

Other Spaces

Web spaces

Space of Parona

Sup. Pulp space Sup. Pulp space

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

Contents

Subcutaneous fatty tissue

Loculated by tough fibrous septa - extending from skin to phalanx.

Sensory nerves Digital Artery

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

Felon

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 Synovial Tendon Sheath Sheath

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 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.

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.

Flexor Tenosynovitis

• Finger in slight Finger in slight flexionflexion

• Fusiform swellingFusiform swelling

• Pain with extension.Pain with extension.

• Tenderness along Tenderness along tendon sheathtendon sheath

Trigger Finger

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

Ulnar & Radial Ulnar & Radial Bursa 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

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.

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.

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.

Ulnar BursaUlnar Bursa

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.

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.

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..

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.

Thenar space Thenar space

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.

Boundaries

Anterior - Palmar aponeurosis / superficial palmar arch, flexor tendon of index finger covered with synovial sheath / tendon of FPL

Posterior – fascia covering adductor pollicis

Boundaries

Lateral - Lateral palmar septum

Medial - MidPalmar septum

Proximal – distal margin of flexor retinaculum

Distal - 1st web space thru lumbrical canal

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

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 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.

Mid – Palmar Mid – Palmar space space

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 – 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

Boundaries

Medial – Medial Palmar septum

Lateral - Midpalmar septum

Proximal – distal margin of flexor retinaculum

Distal - medial 2 web spaces thru lumbrical canals

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.

Mid Palmar infection

Closed space infection of the palmar space.• 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

Other spaces Other spaces

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.

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

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