1. The document describes the anatomy and infections of the hand. It details the bones, muscles, nerves and blood supply of the hand. 2. Common hand infections include paronychia, felon, web space infections, and tenosynovitis. These infections can involve the skin, fascial spaces or tendon sheaths of the hand. 3. Treatment of hand infections involves drainage of pus, antibiotics, elevation and immobilization of the hand. Early recognition and treatment of infections is important to prevent complications and preserve hand function.

1. Hand infections

2. Anatomy of the Hand and
Wrist

3. Mnemonic
for
Learning
Carpals
She Likes To Play
Lunate
In the moonlight
Triquetrum
The third T Bone
Pisiform
Pea-shaped
Try To Catch Her
Trapezium:
“It’s by the thumb”
Trapezoid
“Is by its side”
Capitate
Hamate
A hambone
With a hook
Scaphoid
A boat
Click R Button for Slideshow

4. Main Menu
Surface Anatomy
Essentials of Hand Surgery 2002

5. Small Muscles of the Hand
 Lumbrical muscles (4).
 Palmar interossei muscles (4).
 Dorsal inerossei muscles (4).
 Short muscles of the thumb ( thenar muscles (3) +
adductor pollicis).
 Short muscles of the little finger (hypothenar
muscles (3) .

6. thenar eminence
• is the body of muscle
on the palm of the
human hand just
beneath the thumb.
• Abductor pollicis
brevis, Flexor pollicis
brevis, Opponens
pollicis, Adductor
pollicis
• “OA2F”

7. Adductor pollicis:
• Origin: Oblique head: 2nd
& 3rd metacarpals.
Transverse head: 3rd
metacarpal
• Insertion: base of
proximal phalanx of
thumb.
• Nerve supply: deep
branch of ulnar N
• Function: adduction of
the thumb.

8. Hypothenar eminence
• is the body of muscle
on the palm of the
human hand just
beneath the 5th
phalange
• Abductor digiti minimi
& Flexor digiti minimi
Opponens digiti
minimi
• “OAF”

9. Lumbrical muscles:
• Origin: tendons of flexor digitorum profundus.
• Insertion: extensor expansion of medial four fingers.
• Nerve supply: median nerve(lat.1) and deep branch of
ulnar nerve (med.3).
• Function: flex the MCP joints & extend the IP joints of
medial four fingers.

10. Palmar interossei muscles
• Origin: first, second, fourth,
and fifth metacarpal bones.
• Insertion: proximal
phalanges of thumb, index,
ring, and little fingers and
extensor expansion of each
finger.
• Nerve supply: deep branch
of ulnar nerve.
• Function: adduct the fingers
toward center of third finger
and flex the MCP joints &
extend the IP joints.

11. Dorsal interossei muscles
• Origin: contiguous sides of
metacarpal bones.
• Insertion: proximal
phalanges of index,
middle, and ring fingers
and dorsal extensor
expansion.
• Nerve supply: deep branch
of ulnar nerve.
• Function: abduct the
fingers from center of third
finger and flex the MCP
joints & extend the IP
joints.
•

12. Blood Supply of the Palm
• Arteries:
1. Ulnar artery: it enters
the palm anterior to the
flexor retin. on the lat.
Side of the ulnar N. It
gives a deep branch and
then continue as the
Superficial palmar arch.
This arch curves laterally
deep to the aponeurosis
and in front of long flexor
tendons, it is completed
laterally by one of the
branches of the radial
artery.

13. 2. Radial artery: it enters the
palm from the dorsum of the
hand between the 1st and 2nd
metacarpal bones and curve
medially and continues as
Deep palmar arch. This arch
run deep to long flexor
tendons and in front of
metacarpals and interossei,
then completed medially by
joining the deep branch of
the ulnar artery.
•
• Veins of the Palm:
The superficial and deep
palmar arches are
accompanied by superficial
and deep palmar venous
arches

14. Blood supply of the Dorsum of the Hand
Radial artery
• It enters the dorsum of the
hand deep to the tendon of
the extensor pollicis longus
and gives branches take part
in the anastomosis around
the wrist.
• Dorsal Venous Arch:
• It lies in the subcutaneous
tissue proximal to the MCP
joints and drains on the
lateral side into the cephalic
vein and, on the medial side
into the basilic vein. The
greater part of the blood from
the whole hand drains into
this arch.

15. • The
Three
Nerves of
the wrist
and hand

16. The median nerve
• The median nerve
supplies feeling the
the palmer side of
your 1st, 2nd,3rd, and
medial 4th fingers.
• The Median nerve is
involved with carpal
tunnel syndrome

17. The Ulnar nerve
• The Ulnar nerve supplies feeling and motor
function to the lateral 4th and 5th fingers.

18. The Radial Nerve
• The radial nerve
innervates most of the
extensors and
supplies the feeling
on the dorsal side of
the first three digits

19. Main Menu
Essentials of Hand Surgery 2002
Palmar Fascia
• Provides a stable platform for
the palmar skin & protects the
underlying structures
• Insertion site for the palmaris
longus tendon

20. http://www.mayo.edu/mcj/hand/carpal.jpg

21. Main Menu
Muscle/ Tendon- Palmar
• Carpal tunnel- contents
• Median nerve
• FDS (4), FDP (4), FPL

22. Spaces Of Forearm & Hand
 FOREARM SPACE OF PARONA
 PALMAR SPACES
1. Thenar space
2. Midpalmar space
3. Web space
 DORSAL SPACES OF HAND
1. Dorsal subcutaneous space
2. Dorsal subaponeurotic space
 SUPERFICIAL PULP SPACE OF FINGERS

23. FOREARM SPACE OF
PARONA
 Location
 Boundaries
The space of Parona and its
boundaries.
1 Pronator quadratus;
2 Space of Parona;
3 Flexor carpi ulnaris;
4 Flexor digitorum profundus;
5 Median nerve;
6 Flexor pollicis longus.
Drainage along the ulnar side of the
forearm

24. Fascial Spaces of the Palm
• Are potential spaces
filled with loose
Connective tissue.Their
boundaries are
clinically important
because they limit the
spread of infection in
the palm.
•

25. • From the medial border of palmer aponeurosis a fibrous
septum passes backward and is attached to the anterior
border of the fifth metacarpal bone. From the lateral
border, a second fibrous septum passes obliquely
backward to the anterior border of the third metacarpal
bone. This second septum divides the palm into1. the
thenar space and2. midpalmar space.
1
2

26. These spaces are closed off
proximally from the forearm
by the walls of the carpal
tunnel.
1)Thenar space: it lies
lateral to the septum and
contains the first lumbrical
muscle.
2)Midpalmar space: it lies
medial to the septum and
contains the second, third,
and fourth lumbrical
muscles.
•
1
2

27. • Pulp Space of the Fingers:
The deep fascia of the pulp of each finger fuses
with the periosteum of the terminal phalanx just
distal to the insertion of the long flexor tendons
and closes off a fascial compartment known as the
pulp space

28. Pulp Space of the Fingers:
Each pulp-space is subdivided by the presence of numerous septa,
which pass from the deep fascia to the periosteum. Through the pulp
space, which is filled with fat, runs the terminal branch of the digital
artery that supplies the diaphysis of the terminal phalanx. The epiphysis
of the distal phalanx receives its blood supply proximal to the pulp space.

29. Fibrous Flexor Sheath:
• The anterior surface of each
finger, from the head of
metacarpal to the base of
distal phalanx, is provided
with a strong fibrous sheath
that is attached to the sides
of the phalanges. The fibrous
sheath form a blind tunnel in
which the flexor tendons lie.
It is opened proximally and
closed distally . The fibrous
flexor sheath of the thumb
contains the FPL tendon ,
while the sheath of other
fingers contain the tendons of
FDS & FDP.

30. Synovial Flexor Sheath:
To allow free frictionless
movement of the hand, the
flexor and extensor tendons
are enclosed in two layers of
synovium separated by fluid.
Opposite each finger, the
flexor tendons are enclosed
in a digital synovial sheath,
which in turn is covered by a
fibrous flexor sheath.

31. • The flexor pollicis longus has a separate synovial covering that
is called the radial bursa, while in the palm and distal forearm,
the superficial and deep flexor tendons of the other fingers are
enclosed in the ulnar bursa.
• The radial and ulnar bursae commonly communicate,
while the latter communicates with the digital synovial
sheath of the little finger , These facts are reflected on the
spread of tendon sheath infections

32. RADIAL & ULNAR BURSAE

33. Hand infection

34. causes
1. Trauma
2. Wound (open, penetrating)
3. Blood
it is direct infection by bacteria(G+
staph a.)
90% of cases are due to staph aureus

35. Clinical presentation
1. Redness ,tender, swelling ,loss of
function.
2. Red streaks.
3. L.N.
the site of infection is known by the point
of maximum tenderness rather than the
area of oedema

36. investigations
• Plain X-ray
• Blood sugar

37. Treatment
1. Rest
2. Elevation (bandage in position of
function,flexion of MCP joints, extension
of IP joints, wrist is slightly extended)
3. Antibiotics (staph)
4. If late: Drainage UGA
Tourniquet,rubber drain,C/S ,forceps
5.EARLY mobilization

38. classification
1-cutaneous and subcutaneous infections
A)paronychia
B) subcuticular and subtcutaneous whitlow
C)pulp space infection
D)web space infection
2-fasical spaces infections
A)midplamar space infections
B)thenar space infection
C) hypothenar space infection
D) space of prona infection

39. 3- synovial sheaths infection
A)acute digital tenosynovitis
b) ulnar bursitis
C) radial bursitis
4- bone and joint infections

40. Paronychia
Acute paronychia
• Acute suppurative infection of the nail fold
• the commonest form of hand infections.
Tretment
• Pus can be drained using a fine tipped scalpel to
raise the nail fold and to incise the skin cap
through which pus points.
• If there is a subungual extension, the related
part of the nail is excised to provide proper
drainage

42. Paronychial Drainage

43. Chronic paronychia
develops in the chronically wet nails of
dishwashers.
Associated fungal infection and nail
deformities are common.
The condition is treated by keeping the
hands dry, and with antifungal therapy.
Removal of the nail is commonly required.

45. Subcuticular and subcutaneous whitlow
• Subepithelial collection of pus is called subcuticular
whitlow. Drainage is afforded by excision of the insensitive
roof without anaesthesia.
• If this roof is callous, pus may trickle down through the
dermis forming another subdermal component. The result
is a 'collar-stud' abscess, which requires anaesthesia for
its evacuation.
• A subcutaneous abscess may also form

47. Felon (Pulp-Space Infection)
 Subcutaneous abscess in
pulp space of finger.
 Pressure on the blood
vessels could result in
necrosis of the diaphysis.
 Epiphysis of this bone is
saved because it receives
its arterial supply just
proximal to the pulp
space.

48. Pulp space infection
• Direct penetrating injury
• Throbbing pain
Clinical features and complications.
• In view of the division of this space into tight
compartments, infection with its accompanying oedema
produce a high rise of tissue pressure. This results in
severe pain,
• and if neglected, the likehood of affection of the digital
vessels with septic thrombophlebitis; thus producing
oesteomylitis of the shaft of the terminal phalanx.
• Fortunately complete regeneration can be obtained from
the undamaged proximal part which is supplied by the
epiphyseal branch

50. • Treatment.
• Early surgical drainage is indicated, the incision is sited
directly over the most tender point
• remember "Don't wait for fluctuation in cases of pulp
space infection"

51. SURGICAL TREATMENT
 Longitudinal volar incision
 Unilateral longitudinal
incision
 Bilateral longitudinal
incision

54. Web Spaces
 potential spaces
surrounding the tendon of
each lumbrical muscle,
normally filled with
connective tissue.
 Three in number
 They lie between the index,
middle, ring, and little
finger
 Proximally continuous with
one of the palmar spaces.

55. Web Space Infection
 Most common site
after pulp spaces.
 Pus mostly gathers
near palmar space
but may spread.
 Separation of
adjacent two fingers
 Drainage through
dorsal longitudinal
incision

57. Midpalmar Space
 Location
 Boundaries
 Anterior - the long
flexor tendons to the
middle, ring, and
little fingers.
 Posterior - interossei
and the third, fourth,
and fifth metacarpal
bones

59. Infection Of Mid Palmar Space
 Infection reaches from a
lumbrical canal or infected
tendon sheath or web spase

60.  Marked dorsal oedema
 Drainage through an incision of one of the transverse
palmar creases
 Incision through skin only followed by Hilton
method

61. Infection Of Thenar Space
 Lies under palmar
fascia.
 Bounded dorsally by
transverse head of
adductor pollicis.

62. Thenar Space
 Location
 Boundaries
 The thenar space contains the first lumbrical muscle
and lies posterior to the long flexor tendons to the
index finger and in front of the adductor pollicis
muscle

63.  Ballooning of thenar eminence and oedema of the
dorsum of the hand
 Drainge through the maximum point of tenderness
 Incision that is done along the medial side of the
thenar eminence shoud stop 2 cm distal to the distal
wrist crease to avoid injury of motor branch of
median n

64. Acute Tenosynovitis
• This is the most serious of hand infections.
• Aetiology. It is usually the sequale of deep pin pricks.
• Clinical features.
• Involvement of a digital flexor sheath produces pain and
sweling of the finger
• the patient keeps in the semiflexed position.
• active or passive movement stretches the inflamed
synovium and induces severe pain
• Tenderness is maximum just proximal to the crease
over the metacarpophalangeal joints, which is the
proximal extent of the synovial sac

67. Ulnar bursitis
• Little finger sheath affection is likely to spread to
ulnar bursa
• Marked hand swelling,semiflexion and limitation
of movement of the medial 4 fingers
• Diffuse palm tenderness that may extend to
distal forearm
• Maximum point of tenderness on the ulnar side
between the 2 palmer creases (Kanavel`s sign)
• Radial bursitis produces similar picture

68. • Complications.
1. Thrombo-phlebitis of the tendon vessels leads to its
sloughing. The end result is a stiff useless finger.
2 Infection may also spread to the midpalmar space and to
the space of Parona.

69. SURGICAL TREATMENT
 Two methods:
Closed irrigation- 2 incisions
 Proximal
 Distal
Open drainage and debridement- 2
incisions
 1st- Over pulley.
 2nd – Over digit.

70. Osteomylitis
1. Trauma
2. Neglected person
3. Rx antibiotics and if pus,drainage.

71. Incisions for
drainage of
abscess