You are on page 1of 40

Anatomical spaces of

diffusion of infection of
the hand
Christian Dumontier
Centre de la Main, Guadeloupe

The school of Chicago
with Drs. Alan Kanavel,
Sumner Koch, Michael
Mason, and Harvey Allen
were founders of
modern hand surgery

In his book Kanavel
describes the
anatomical spaces
through which
infections spread
and how to
correctly drain the
abscesses

Rare

Anatomical spaces
Deep, clearly
delineated
3 spaces at the hand:
Thenar, mid-palmar &
hypothenar
1 space at the distal
forearm (space of
Parona)

Gaines ulnaire et radiale
Superficial, poorly
limited
Dorsal (sus or subaponeurotic)
Interdigital or web
space

Digito-carpal flexor
tendon sheaths
The radial sheath and
FPL communicate in all
subjects
Ulnar sheath and the
sheath of the little finger
communicate in 80% of
individuals
Radial and ulnar sheath
communicate at the
wrist in 50-80% of
individuals
Many variations

Digito-carpal sheath

Communication with the ulnar
sheath (367 cas)
Index 5,1%
Middle 4.0%,
Annular 3.5%
The sheath of II & III may arise
from the radial sheath
Isolated sheath for the
index running from the
wrist to the distal phalanx !
- variations +++

MRI of a balancing septic synovitis

Dorsum of the hand
Two spaces: over and under
the extensor tendons
Zone of diffusion without
defined borders ☞ diffuse
swelling, sometimes little pus
with large skin detachment
Difficult and frustrating to
drain

Dorsum of the hand
Excision of entry portal
To extend: Two incisions
over the radial side of
the index and 4th web
(not to expose the
tendons)
Avoid « lame »

Superficial infection over the back of the hand

Interdigital spaces
Complex anatomy with
crossing of pedicles,
lumbricals and fibrous
structures
Superficial: Natatory
ligament (distal) and
palmar transverse
ligament (proximal)

Commissures
Infection is initally volar
and spreads dorsally
(looser tissues)
Collar-button abscess
Finger Abduction (≉ dorsal
infection is not accompanied
with finger abduction)

Palmar transverse
ligament (Skoog)

Natatory ligament

Treatment
Débride both sides of
the web +++
Two incisions
Beware of pedicles
(arteries)

Deep spaces of the hand

Thenar
Mid-palmar
Hypothenar

Common clinical findings

Dorsal swelling +++ (no possible volar
expansion) except hypothenar space
Palmar swelling and pain

Limits
Medial: 3rd metacarpal, oblique
fascia oblique between the 3rd
metacarpal and the palmar
fascia
Dorsal: fascia of adductor
pollicis
Volar: Index sheath and palmar
fascia
Radial : coalition of the palmar
fascia and the aponeurosis of
the adductor policies over the
1st phalanx of the thumb

Flynn, 1942

Limits
Proximal: Carpal
tunnel
Distal: Palmar
transverse ligament
(Skoog)

Thénar space Infection
Not to forget X-rays

The most frequent
Local wound or spreading
of septic tenosynovitis of
the thumb, index or middle
finger
Severe and painful swelling
Thumb in « irreducible »
abduction +++
Sometimes index in flexion

Thenar space Infection
Expansion to the dorsal side with
destruction of adductor fascia and
spreading of the pus between the two
heads of the 1st interosseous muscle

Some
examples

Treatment
No incision in the axis
of the web (retraction)
Two incisions most
often
Do not forget to drain
up to the middle of the
palm +++

Anatomical limits of the midpalmar
space

Proximal: Carpal
tunnel
Distal: Palmar
transverse ligament
(Skoog)

Dorsal: Fascia of 2nd and
3rd palmar interosseux and
periosteum of 3,4 & 5th
metacarpals
Volar : Flexor sheath of 3,4
& 5 and oblique fascia
Radial: Oblique fascia
Ulnar: Hypothenar fascia
between the palmar fascia
and 5th metacarpal

Flynn, 1942

Midpalmar Space Infection
Rare: either penetrating
wound or expansion of a septic
tenosynovitis of IV/V
Tense and painful palm
Loss of palmar concavity
III and Iv finger in a
« reducible » position of
flexion
Dorsal swelling

Treatment

Surgical drainage
(difficult because of the
« rich » anatomy)
Many possible incisions
(do it large)

Hypothenar space
Infection
Very rare, after wounds
No possible expansion
Localized pain and
swelling (not dorsal)

Discussion: Does the oblique fascia do exist ?
Probably not ? Thenar space infection does not expand in the
midpalmar space usually but there is not a true separation

Space of Parona (Francesco Parona, 1876)

Distal: Carpal tunnel
Proximal: Flexor
superficialis muscles
Dorsal: Pronator
quadratus and
interosseous membrane
Volar: flexor tendons

Space of Parona

up to 85% of patients:
communication
between the radial and
ulnar sheath and the
midpalmar space

Infection of the space of Parona

From the radial sheath : 7 cases
From the ulnar sheath: 1 case
From the midpalmar space: 1 case
2 surgical debridement on average (1-5)

Sharma KS. Space of Parona infections. JPRAS 2013;66:968-972

In every case, do not forget
Repeat dressings
Early mobilization (in a bassin with diluted
povidone iodine ?)
Immobilization and hand elevation between
rehabilitation
Adapt antibiotics to samples +++
70-80% good results