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THE ANATOMICAL BASIS AND

SURGICAL MANAGEMENT OF
ACUTE INFECTIONS OF THE HAND

Christian Dumontier, MD, PhD


Centre de la Main, Guadeloupe, FWI

www.diuchirurgiemain.org
PLAN
• Physiology of infection

• Surgical treatment

• Anatomical spaces
and surgical
implications

Kanavel Allen B. An anatomical, experimental, and clinical study of acute phlegmons of the hand Q Bull Northwest Univ Med
Sch. 1906 March; 7(4): 384–446.
ACUTE INFECTION:
THE DIFFERENT PHASES

• Inoculation: Entry point with


bacterial inoculation

• May be forgotten or unknown

• Inflammation

• Infection

• Complication
ACUTE INFECTION:
THE DIFFERENT PHASES

• Inoculation:

• Inflammation:

• Spontaneous pain, less severe at


night, local inflammatory signs

• Medical treatment (Hand elevation,


Rest, Hexamidine soaked dressing)

• Antibiotics ?

• Infection

• Complication

Patient burned by Dakin


ACUTE INFECTION:
THE DIFFERENT PHASES

• Inoculation:

• Inflammation:

• Infection:

• Pain, intense, pulsatile, permanent, increased at


night

• Tense, red, hot -Sometimes the pus is visible

• May have epitrochlear or axillary ganglia, lymphangitis,


Fever, ➚ VS, ➚ CRP, Hyperleucocytosis

• Complication
ACUTE INFECTION:
THE DIFFERENT PHASES

• Complication: = diffusion of
the infection into closed
spaces (joints, sheaths), bone,
anatomical spaces of diffusion
SURGICAL TREATMENT

• Urgent

• Regional anesthesia (avoid


local)

• EXCISION of all infected


tissue

• Bacteriological samples
SURGICAL TREATMENT

• Abundant lavage

• Leave the wound


open

• No « artificial »
drainage
SURGICAL TREATMENT

• Hand surelevation

• Postop dressing at day 2-4.


Wound should be perfect

• Antibiotics are not needed


usually

• Starts rehabilitation if
needed as early as possible
Pierrart J et al. Acute felon and paronychia: Antibiotics not
necessary after surgical treatment. Prospective study of 46
patients. Hand Surg Rehabil. 2016 Feb;35(1):40-3.
ANATOMICAL SPACES: FINGER

• Pulp

• Perionychium

• Dorsal space

• Volar space

• Flexor Sheath index to ring


PERIONYCHIUM
• Extend along the proximal
nail fold

• May diffuse

• Under the nail plate


(rare)

• Into the pulp under Flint’s


interphalangeal ligament
PULP

• « Closed sac »

• May extend to the flexor


sheath or the anterior
finger space along the
pedicles

Hauck RM, et al. Pulp Nonfiction: Microscopic Anatomy of the Digital Pulp Space. Plast. Reconstr. Surg. 2004; 113: 536-539.
DORSAL DIFFUSION AT THE FINGER

• Rare (no real space)

• Phlyctenulae are quite frequent


VOLAR DIFFUSION AT THE FINGER

• The flexor sheath

• The anterior space


long the pedicles
FLEXOR TENDON SHEATH
• Many variations +++

• Communication with the ulnar sheath (367 cases)

• 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 !
ANATOMICAL SPACES: HAND
• Deep, clearly delineated

• 3 spaces at the hand: Thenar, mid-


palmar & hypothenar

• 1 space at the distal forearm


(space of Parona)

• Ulnar and radial sheaths

• Superficial, poorly limited

• Dorsal (sus or sub-aponeurotic)

• Interdigital or web space


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

• To extend : Two incisions over the


radial side of the index and 4th web
(not to expose the tendons)

• Avoid Penrose drains and other foreign


bodies !
WEB SPACES
• Complex anatomy with crossing of
pedicles, lumbricals and fibrous
structures

• Superficial: Natatory ligament


(distal) and palmar transverse
ligament (proximal)

• Infection is initially volar and


spreads dorsally (looser tissues) -
Collar-button abscess

• Finger Abduction (≉ dorsal infection is not


associated with finger abduction)
SURGICAL IMPLICATIONS

• Debride both sides of the


web +++

• Two incisions

• Beware of pedicles (arteries)


DIGITO-PALMAR SHEATHS
• The radial sheath and FPL
communicate in all subjects

• Radial flexor sheath infection should be


opened 3-4 cm above the wrist crease
and at the IP joint
ULNAR DIGITO-PALMAR SHEATH

• Ulnar sheath and the sheath


of the little finger
communicate in 80% of
individuals (Gardner), 50%
(Poirier & Resnick ), 71 %
(Scheldrup)

• But only 30% (Phillips)

Phillips CS et al. The flexor synovial sheath anatomy of the little finger: a macroscopic study. J Hand Surg 1995;20A:636-641
• 50% of the little finger
sheaths end at the
level of the palmar
transverse ligament

• 30% are in continuity


with the ulnar sheath

• 20% end at the level


of the A1 pulley

Phillips CS et al. The flexor synovial sheath anatomy of the little finger: a macroscopic study. J Hand Surg 1995;20A:636-641
DIGITO-PALMAR SHEATHS

• Radial and ulnar sheath


communicate at the wrist in
50-80% of individuals

• Up to 85% of patients:
communication between
the radial, ulnar sheath and
the midpalmar space
DEEP SPACES OF THE HAND
• Thenar

• Mid-palmar

• Hypothenar:

• Very rare, after wounds

• No possible expansion

• Localized pain and swelling


(not dorsal)
DEEP SPACES OF THE HAND
• Thenar

• Mid-palmar

• Between the two: 3rd metacarpal, oblique fascia


between the 3rd metacarpal and the palmar fascia

Dorsal swelling AND


Palmar swelling and
pain
BOUNDARIES OF HAND SPACES
• Proximal: carpal tunnel

• Distal: Palmar transverse


ligament (Skoog)

• Between the two: 3rd


metacarpal, oblique fascia
between the 3rd Flynn, 1942
metacarpal and the palmar
fascia
• 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
THENAR SPACE
• Limits :

• Medial: oblique fascia

• Dorsal: fascia of adductor


pollicis

• Volar: Index sheath and palmar


fascia

• Radial : coalition of the palmar


fascia and the aponeurosis of
the adductor pollicis over the
1st phalanx of the thumb
SURGICAL IMPLICATIONS
• No incision in the axis of the web
(retraction) - Two incisions

• Do not forget to drain up to the


middle of the palm +++
THE MID-PALMAR SPACE
• Dorsal: Fascia of 2nd and 3rd
palmar interosseux and
periosteum of 3,4 & 5th
metacarpals

• Volar : Flexor sheath of 3,4 & 5 Flynn, 1942


and oblique fascia

• Radial: Oblique fascia

• Ulnar: Hypothenar fascia


between the palmar fascia and
5th metacarpal
MID-PALMAR SPACE
• Rare infection : 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
SURGICAL
CONSEQUENCES

• Surgical drainage is difficult


because of the « rich »
anatomy

• Many possible incisions (do


it large)
SPACE OF PARONA (FRANCESCO PARONA, 1876)

• Limits are:

• Distal: Carpal tunnel

• Proximal: Flexor
superficialis muscles

• Dorsal: Pronator
quadratus and
interosseous membrane

• Volar: flexor tendons


Sharma KS. Space of Parona infections. JPRAS 2013;66:968-972
CONCLUSION
• Apart from the
pathophysiology of hand
infection

• Knowledge of the anatomy


to correctly treat your
patients is mandatory as
infections tend to spread
from a compartment to
another