Spaces of hand

1. Facial spaces of Hand

2. Spaces Of Hand
• Palmar spaces
• Thenar space
• Midpalmar space
• Web space
• Pulp space of fingers

6. Thenar space
• Boundaries
Anterior
1. Palmar aponeurosis
2. Flexor tendon of index finger
3. Short muscles of thumb
4. Lumbricals (1 & 2)
Posterior
1. Adductor pollicis (trans)
Radial
Lateral palmar septum
Medial
Intermediate palmar septum

7. Thenar space
• Proximally
• Distal margin of flexor retinaculum
• Distally
• Distal transverse palmar crease
• Communication
• With I web space
• Through lumbrical canal

8. Midpalmar space
• Boundaries
Anterior
1. Palmar aponeurosis
2. Flexor tendons of medial 3 fingers
3. Lumbricals (3 & 4)
Posterior
1. Fascia over the interossei of 3rd & 4th space
Radial
Intermediate palmar septum
Medial
Medial palmar septum

9. Midpalmar space
• Proximally
• Distal margin of flexor retinaculum
• Distally
• Distal palmar crease
• Communication
• From distal end
• With 2nd, 3rd & 4th lumbrical canals
• Lumbrical canal
• Space surrounds the tendon of lumbrical

10. Web space
• 4 subcutaneous spaces
• Extent
• From free margin of web
• To the metacarpophalangeal joint
• Content
• Fat
• Superficial transverse palmar
ligament
• Tendons of
• Interossei & lumbicals
• Digital nerves & vessels

11. Fibrous flexor sheath
• Fibrous sheath covering the digits
• On anterior surface of the fingers and
attached to the sides of the phalanges
• Forms an Osteofibrous blind Tunnel
• To retain the tendons in position
• Covering the long flexor tendons
• Thumb
• Flexor pollicis longus
• Medial 4 fingers
• Flexor digitorum profundus
• Flexor digitorum superficialis

12. Fibrous flexor sheath - Extent
• From
• Head of Metacarpal
• Proximal end is opened
• To
• Base of Distal phalanx
• Distal end is closed

13. Fibrous flexor sheath
• 2 types of arrangement
• Annular (5)
• Joints (3)
• Middle of proximal & middle phalanges (2)
• Cruciate (4)
• Between the annular arrangement
• Thick
• Opposite to phalanges
• Thin
• Opposite to joints
• To allow free movement

14. Pulp space
• Subcutaneous space
• Between
• Distal phalanx
• &
• Skin
• Proximal
• Fusion of fibrous flexor sheath
• Space is divided into many compartments
by fibrous septa

15. Applied anatomy
• Infection of this region
• Known as whitlow or felon
• Distension of any compartment by
pus
• Presses on nerve endings
• Necrosis of distal 4/5th of distal phalanx
may happen
• If whitlow is not treated
• Why
• Blood supply is from the branches arising within
this space
• Proximal 1/5th part of distal phalanx is getting
supply from the branch which does not traverse
the pulp space

16. Dorsal subcutaneous space
• Lies immediately below the skin in the
dorsum of the hand

17. Arterial supply to hand
• Hand has rich arterial supply
• Many anastomoses
• Allows the hand get blood supply
• Grasping or applying pressure
• Supplied by
• Ulnar and radial arteries

18. Palmar arches
• Superficial palmar arch
• Above long flexor tendons
• Deep palmar arch
• Below long flexor tendons

19. Superficial palmar arch - location
• Lies beneath
• Palmar aponeurosis
• Superficial to
• Long flexor tendons
• Lumbrical
• Palmar digital branches of
median nerve

20. Superficial palmar arch - formation
• Ulnar artery enters palm
• Above the flexor retinaculum
• Lateral to pisiform
• Beneath palmaris brevis
• Here it divides into
• Superficial
• Deep
• Superficial branch turns laterally

21. • Ulnar artery is main contribution
• Superficial branch of ulnar artery
• Continues as superficial palmar arch
• Mode of completion
• By one of the following branches of radial
artery
• Superficial palmar branch
• Arteria princeps pollicis
• Arteria radialis indicis
Superficial palmar arch - formation

22. Superficial palmar arch - branches
• 1 proper palmar digital branch
• Supplies ulnar side of little finger
• 3 common digital branches
• Reaches the web between medial 4 fingers
• Each artery divides into
• 2 proper palmar digital arteries
• To supply adjacent fingers
• Superficial palmar arch supplies
• Medial 31/2 fingers

23. • At web
• Common palmar digital
• Branch from superficial palmar arch
• Palmar metacarpal
• Branch from deep palmar arch

24. Relations
• Superficially
• Palmaris brevis & palmar aponeurosis
• Deep
• Flexor digitorum tendons
• Flexor digiti minimi
• Lumbricals
• &
• Median nerve branches

25. Radial artery
• Proximal to flexor retinaculum
• Superficial palmar branch
• Passes into palm by
• Over the thenar muscles
• or
• Piercing through thenar muscles
• Usually superficial palmar branch will
anastomose
• To form superficial palmar arch

26. Radial artery
• At wrist
• Lies beneath tendons of
• Abductor pollicis longus
• Extensor pollicis brevis
• Crosses anatomical snuff box
• Enters the palm
• In between the 2 heads of dorsal
interossei
• In the palm
• Passes in between oblique and transverse
heads of adductor pollicis

27. Radial artery
• In the palm
• Between the 2 heads of adductor
longus it gives
• Arteria princeps pollicis
• Passes beneath oblique head of
adducor longus along I metacarpal
• At proximal phalanx divides into 2
branches
• Supplies both sides of thumb
• Arteria radialis indicis
• Passes in between
• Transverse head of adductor
longus and first dorsal
interosseous
• Supplies
• Radial side of index finger

28. Deep palmar arch
• Continuation of the radial artery
• Passes medially
• Lies deep to
• Oblique head of adductor pollicis
• Long flexor tendons
• Lumbricals
• Passes transversely on
• Bases of metacarpals
• Interossei
• Completed on the medial side by
• Deep branch of ulnar artery
• Surface marking
• At the level of proximal border of outstretched
thumb
• 1 cm proximal to superficial palmar arch

29. Deep palmar arch
• Formed by continuation of radial
artery and completed by deep branch
of ulnar artery
• Branches
• 3 palmar metacarpal arteries
• 3 perforating
• With dorsal metacarpal arteries
• Recurrent branches
• Anastomose with anterior carpal arch

30. Dorsal metacarpal arteries
• 1st dorsal metacarpal
• From radial
• 2nd , 3rd, & 4th dorsal metacarpal
• From dorsal carpal arch

31. Allen's test
• To test for adequate
anastomoses between the radial
and ulnar arteries
• Compress both the radial and
ulnar arteries at the wrist
• Then release pressure from one
or the other
• and
• Determine the filling pattern of
the hand

32. How to control bleeding in hand
• Compression of brachial artery
• Against humerus
• Why not at wrist by arresting
ulnar & radial arteries
• There is communication between
palmar & dorsal carpal arches
with arterial arches of palm