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SURGICAL ANATOMY OF HAND AND IT’S INFECTIONS
Dr SD SanyalLt Col R Venkatnarayan
HAND ANATOMY
The hand is the region of the upper limb distal to the wrist joint.
It is subdivided into three parts: 1. Wrist 2.Metacarpus 3.Digits (five fingers including the thumb). The hand has an anterior surface (palm)
and a dorsal surface (dorsum of hand).
HAND
Palmar aponeurosis Blood supply Nerves Carpal tunnel Guyon’s canal Palmar spaces Nail anatomy
Hand
The palmar aponeurosis is a triangular-shaped condensation of deep fascia that covers the palm and is anchored to the skin in distal regions.
The apex of the triangle is continuous with the palmaris longus tendon.
Palmar Aponeurosis
Palmar Aponeurosis
Figure 4 Anatomy of the radial artery
Byrne, R. A. et al. (2012) Vascular access and closure in coronary angiography and percutaneous intervention
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2012.160
Cutaneous Innervation of Ulnar Nerve
Cutaneous Innervation of Radial Nerve
Cutaneous Innervation of Median Nerve
All of the intrinsic muscles of the hand are innervated by the deep branch of the ulnar nerve except for the three thenar and two lateral lumbrical muscles, which are innervated by the median nerve.
Innervation of muscles
The carpal tunnel is formed anteriorly at the wrist by a deep arch formed by the carpal bones and the flexor retinaculum.
Carpal tunnel and structures at the wrist
Four tendons of the flexor digitorum profundus
Four tendons of the flexor digitorum superficialis
One tendon of the flexor pollicis longus
Median nerve
Structure and relations
Carpal Tunnel
Guyon’s Canal
1. Hypothenar compartment
2. Thenar compartment 3. Central compartment 4. Adductor
compartment 5.Interosseous
compartment
Compartments of palm
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
MidPalmar space Thenar space Hypothenar space Radial Bursa Ulnar bursa
Palmar Spaces
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
Midpalmar 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
Thenar Space
Posterior – 5th Metacarpal
Lateral – Hypothenar septum
Medial & Ant– Hypothenar Muscles
Hypothenar Space
Synovial sheath surrounding Flexor Pollicis Longus tendon
Extends from forearm( 2 cm prox to Flexor retinaculum) to base of terminal phalanx of thumb
Radial 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
Ulnar Bursa
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.
Web Spaces
Nail AnatomyA. Nail plateB. LunulaC. RootD. SinusE. MatrixF. Nail bedG. HyponychiumH. Free edge
Hand Infections
Infection of the soft tissues surrounding the fingernail and is the most common infection of hand.
PARONYCHIA
Cause:◦ Inocculation of bacteria as a consequence of
minor trauma such as Nail bitiing Poor manicuring Small puncutre wounds.
Staph aureus is most common pathogen but anaerobes may also be involved.
UNCOMPLICATED INFECTION:◦ Oral antiboitics / Rest / Heat / Elevation
INFECTION WITH ABSCESS:◦ Localized to one nail fold;
Elevation of fold bluntly with a haemostat Using no 11 blade directing away from nail bed
through the insensate epithelium where abcess is pointing.
◦ Eponychia (involving proximal nail & one lateral fold; Elevating the eponychial fold and removal of loose
portion of nail plate to drain abscess and allow for secondary healing.
A felon is an abscess of the distal pulp of the thumb or finger.
FELON
Pulp Anatomy:◦ 15-20 longitudonal septa anchoring skin to distal
phalanx dividing the pulp into multiple closed compartments.
Pathophysiology:◦ Abscess formation within these small
compartments results in rapid development of swelling and throbbing pain, worsened by dependency.
Complications:◦ Necrosis of entire pulp◦ Extension of infection into;
Flexor tendon sheath Distal IP joint Distal phalanx.
Causes:◦ Mostly Puncture wound with foreign body, so
radiographs are mandatory. Pathogen:
◦ Staph aureus but gram –ve infection can also occur esp in immunocompromised patients.
Conservative Management: For early Felons…◦ Oral antiboitics◦ Rest◦ Warm Soaks◦ Elevation.
Herpex simplex virus infection can be:◦ Primary◦ Recurrent
Population at risk:◦ Children, adolesents with genital herpes infection◦ Health care workers with frequent exposure to
oral secretions. Must be distinguished from Paronychia and
Felon because incision and drainage is generally contraindiacted.
HERPETIC WHITLOW
Pathophysiology:◦ A prodromal phase of 24-72 hours of burning pain
prior to the development of skin changes.◦ Erythema and swelling◦ Formation of clear vesicles which sometimes
coalesce around nail fold.◦ Fluid may become turbid but not frankly purulent
unless bacterial superinfection occurs.◦ Pulp of affected digit is not tense as in felon.
Disease Course:◦ The process occurs over approx 2 weeks and
resolves over next 7-10 days. Diagnosis:
◦ Viral culture◦ Tzanck smear
Treatment: Generally conservative◦ Rest & Elevation◦ Anti inflammatory agents◦ Acyclovir in immunocompromised states.
Reccurence rates are around 20%.
Thenar space Midpalmer space (subtendinous space) Hypothenar space Dorsal subapeneurotic space Web spaces.
◦ Thenar and midpalmer spaces are clinically more important.
PALMER SPACE INFECTIONS
MIDPALMER SPACE INFECTION
THENAR SPACE INFECTION
A penetrating injury usually a splinter is the most common cause.
Staph aureus is the usual pathogen. Antiboitics / Rest / Heat / Elevation for early
infections but most cases need Surgical Drainage.
Key to success is adequate drainage while avoiding iatrogenic injury and subsequent scar contracutres.
Curved longitudonal incision in the palm. Take care to avoid injury to superficial
palmer arch and digital vessels. Wound packed open with daily dressing
changes. OR Irrigation catheter in proximal wound and a
penrose drain in distal wound for continous or intermittent irrigation.
Midpalmer space infection incisions and proceedures:
Combined dorsal and volar incisions. Take care to avoid injury to palmer
cutaneous branch of median nerve in proximal end of incision
And avoiding injury to motor branch of median nerve.
Post op care include◦ Splinting◦ Dressing changes◦ Catheter irrigation.
Thenar space infection incision and procedure:
Most serious hand infection. If left untreated;
◦ Destruction of gliding surfaces in sheath◦ Necrosis of tendons◦ Osteomyelitis◦ Amputation.
Ring, middle and index fingers mostly involved Staph aureus usual pathogen with few cases
due to haematogeneous spread of gonococcal infection.
TENOSYNOVITIS
KANAVEL cardinal sign of flexor tenosynovitis:
1. Fusiform swelling of finger2. Paritally flexed posture of digit3. Tenderness over entire flexor sheath4. Dipropotionate pain on passive extension.
PRINCIPLESOF MANAGEMENT
IV antiboitcs is the most common justification for hospitalization.
Continuous or intermittent wound irrigation.Frequent dressing changes.Three phases of treatment in cases of
severe infections where extensive debridement and complex reconstructions are needed.
INPATIENT CARE
Phase 1> Rapid infection control and staged debridement.◦ A second look surgery done in 24-48 hours.
Phase 2> Salvage of vital structures and soft tissue coverage.◦ With identification of structures that will later
require reconstruction. Phase 3 > Reconstructive Surgery.
◦ Once stable soft tissue coverage is achieved.
1. Incisions should never cross a flexion crease at a right angle
2. Avoid iatrogenic injury to critical structures1. Tendons2. Neurovascular bundles
3. Incision lengthening is usually needed and should be planned by making potential extensions with a pen.
OPERATIVE PRINCIPLES
4. Torniquet Control is helpful as infective process can lead to profuse bleeding.
o Finger Torniqueto Penrose draino Glove technique
oStandard Pnematic Torniquet with exanguinationo Esmarch bandageo Elevation of limb with digital pressure on brachial
artery.
a. REST (IMMOBILIZATION)o Limits opening of tissue plans restricting the
spread of infection.o Should be done in a functional position.
REST – HEAT - ELEVATION
b. HEAT (WARM MOIST SOAKS):o Maximum vasodilatory effect reached in 10 min.o Frequent soaks preferred over continuous
soaks.o Severe Infections:
o Moist hot towels with plastic barrier and a dry towel as insulator.
c. ELEVATION:o Reduces edema by improving venous/lymphatic
drainage.o Limb should be above level of heart for
dependant drainage.o Limb placed over chest or on a pillow while
sitting.
Position for Long Term Immobilization
Metacarpalphalangeal joints in 60 to 70 degrees of flexion
PIP and DIP joints extended
FelonsTreatment
FelonsTreatment
Location of Incisions:Index, middle & ring: ULNAR SIDEThumb & small: RADIAL SIDE
ParonychiaTreatment
Eponychia: Elevate eponychial fold and excise prox 1/3 of nail Lateral (paronychial) incisions may aid in separating the
nail base if not already separated
ParonychiaTreatment
2 basic approaches: Open vs. Closed
Open drainage: Decompression of the entire tendon
sheath via mid-axial & palmar incisions Wounds are left open to drain & heal
secondarily Rehab is prolonged; permanent finger
stiffness not infrequent Most useful for advanced cases where
resection of necrotic tendon is required
TenosynovitisSurgery
These incisions: ensure adequate drainage heal quickly Do not interfere with rehab
After removal of catheter and drains begin gentle passive & active ROM
TenosynovitisTreatment
Subfascial and Subpalmar spaceIncisions
Drain via volar or dorsal incisions in the 1st web space or both: Identify neurovascular structures unroof the adductor fascia to open
the abscess cavity irrigate & debride catheter in volar incision & close;
penrose in dorsal incision & close compressive dressing & plaster splint
Thenar Space InfectionsTreatment
Drain via wide palmar incisions with +/- resection of palmar fascia to ensure drainage of abscess cavity.
or may place irrigation catheter & drain and close primarily.
Midpalmar Space InfectionsTreatment
Closed irrigation using 2 incisions, a catheter & a drain as previously outlined.
Bursal InfectionsTreatment
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