This document provides an overview of hand anatomy and infections of the hand. It begins with the anatomy of muscles, blood supply, nerves, and structures of the hand such as the flexor retinaculum. It then discusses localized infections including subcutaneous infections, tenosynovitis, and arthritis. It also covers spreading infections such as lymphangitis and cellulitis. Specific infections described in detail include paronychia, felon, and infections of the palmar and dorsal spaces. The document provides clinical features, investigations, and treatment approaches for various hand infections.

1. INFECTIONS OF
THE HAND
MERU.J.YALE
ROLL NO:71

2. Anatomy of hand

3. Muscles
•Thenar muscles :abductor pollicis brevis, flexor pollicis brevis, opponens pollicis and adductor
pollicis.
•Hypothenar muscles :Palmaris brevis, abductor digiti minimi, flexor digiti minimi and opponens
digiti minimi.
•4 Lumbricals
•4 palmar interossei
•4 dorsal interossei

4. Blood supply
•Superficial palmar arch is mainly formed by ulnar artery and completed by
superficial palmar branch of radial artery.
•It gives 4 digital branches to medial 3 fingers.
•Deep palmar arch is formed by radial artery and is completed by deep branch of
ulnar artery.
•It gives 3 palmar metacarpal arteries which communicate with superficial palmar
arch. It gives communicating, perforating branches to dorsal metacarpal arteries.

5. Nerve supply
•Abductor pollis brevis,flexor pollicis brevis, opponens pollicis and 1st
and 2nd
lumbricals are supplied by
median nerve
•Rest by ulnar nerve

6. Flexor retinaculum
It is a strong fibrous band which bridges
anterior cavity of carpus and converts it into a
tunnel, carpal tunnel.

7. Attachments
Medially,
1.pisiform bone.
2.Hook of hamate.
Laterally,
1.Tubercle of scaphoid
2.Crest of trapezium.
On either side, retinaculum has a slip:
1.Lateral slip- attached to medial lip of groove on trapezium – tunnel for tendon of flexor carpi radialis
2.Medial slip(volar carpal lig)- attached to pisiform bone.ulnar vessels and nerves pass deep to this slip.
structures superficial to FR
1.Palmar cutaneous branch of median nerve.
2.Tendon of palmaris longus.
3.Palmar cutaneous branch of ulnar nerve.
4.Ulnar vessels.
5.Ulnar nerve.thenar and hypothenar muscles arise from FR.
Structures deep to FR
1.median nerve
2. 4 tendons of flexor digitorum superficialis.
3.4tendons of flexor digitorum profundus.
4.Tendon of flexor pollicis longus.
5.Ulnar bursa.
6.Radial bursa.
7.Tendon of flexor carpi radialis.

8. Palmar aponeurosis
•It is the thickened deep fascia of the palm.
•It fixes the skin of the palm and improves the grip.
•It also protects the underlying tendons,vessels and nerves.
•Triangular in shape,apex is proximal,blends with FR – continuous with tendon of palmaris longus.
•Base is directed distally.
•Divides into 4 slips opp heads of metacarpal.
•From lateral and medial margims –palmar septa pass backwards and divide the palm into compartments.

9. MODIFIED VERDAN
ZONE SYSTEM in
HAND
(TENDON ZONES)

10. Modified verdan zone system in the hand
Zone I: from fingertip up to attachment of flexor digitorum superficialis.It
contains tendon of flexor digitorum profundus
Zone II: It begins proximal to metacarpophalangeal joint at distal palmar crease
and extends up to attachment of flexor digitorum superficialis at middle of middle
phalanx.
it is called no-man’s-land here flexors are tightly enclosed within a fibro-osseous
tunnel.It is the most dangerous zone in hand injuries (critical zone).
Zone III: it begins at the distal end of flexor retinaculum and ends at the
transverse crease of the palm. It contains lumbricals attached to flexor digitorum
profundus.
Zone IV: It begins at the proximal end of the flexor retinaculum and ends at its
distal end.
Zone V: It extends from proximal end of flexor retinaculum up to distal third of
the forearm

11. SPACES OF THE HAND
A.PALMAR SPACES
1.Pulp space of the fingers
2.Midpalmar space
3.Thenar space
B.DORSAL SPACES
1.Dorsal subcutaneous space
2.Dorsal subaponeurotic space
C.The forearm space of parona

14. Forearm space of parona
•Rectangular space
•It lies front of pronator qadratus ,deep to long flexor tendons.
•Superiorly, up to origin of flexor digitorum superficialis.
•Inferiorly, to FR
Synovial sheath
Digital Synovial Sheath
•Sheaths of 2nd
,3rd
and 4th
digits are independent ,terminate proximally at head of
metacarpal.
•Sheath of little finger – continuous with ulnar bursa.
thumb-continuous with radial bursa.
Ulnar bursa
•Infection here results in hour-glass swelling.

15. Web space
•Triangular space b/w adjacent fingers bounded by dorsal and volar skins.
•Each side- bounded by digital slips of palmar aponeurosis.
•Filled with loose connective tissue and fat.
•Anterior part of each space- lumbrical muscle,digital vessels and nerves.
•Smaller posterior part contains interosseous muscles.
•Distally – continuous with loose connective tissue on side of finger.
•Proximally- communicates with deep fascial spaces of the palm- lumbrical canals.

17. • Hand- actively functioning unit.
• contains neurovascular bundles, muscles,bones and ligaments.
• Infections of the hand m/c manual workers and housewives.
• Small abrasion, pricks or careless cutting of nails
• Sometimes the cause unknown
• In m/c organism is the Staph.aureus, Strep.pyogenes and gram negative
bacilli.

18. Precipitating causes
• Diabetes
• Immunosuppression
• Trauma
• HIV infection
• Steroid therapy
• Vascular diseases

19. LOCALIZED
INFECTION
SPREADING
INFECTION
INFECTIONS OF HAND

20. 1.SUBCUTICULAR INFECTION
•Subcuticular abscess
• Acute paronychia
•Chronic paronychia
•Apical subungual infection
2.SUBCUTANEOUS INFECTION
•Pulp space infection
•Infection of the middle volar space
•Infection of the proximal volar space
•Web space infection
LOCALIZED
INFECTIONS

21. LOCALIZED
INFECTIONS
3.SUPPURATIVE TENOSYNOVITIS
•Infection of the ulnar bursa
•Infection of the radial bursa
4.PYOGENIC ARTHRITIS OF THE FINGER
5.INFECTION OF THE CELLULAR SPACES OF
THE HAND
•Infection of the superficial palmar space
•Infection of the middle palmar space
•Infection of the thenar space
•Infection of the dorsal space
•Infection of the Parona’s space

22. 1. LYMPHANGITIS
2. CELLULITIS
SPREADING
INFECTIONS

23. Subcuticular abscess
Intracutaneous
abscess
Septic blister
• Palmar surface of the digits and webs.
• Pus collects within the layers of the skin to lift epidermis
from dermis.
• Abscess may communicate with subcutaneous abscess
through small hole called collar-stud abscess. Rx
•Excise overlying epidermis to drain
abscess
•Look for communication with deeper
abscess.
•Small hole is enlarged to drain
subcutaneous abscess and lay open deep
abscess.

26. Acute Paronychia
• It is the most common hand infection.
• Inflammation commences beneath the eponychium.
• Suppuration burrows beneath base of nail.- Hang nail/floating nail
• Infection is subcuticular – dermis
• Infection arises from careless nail paring /manicurist’s unsterile instruments.
Infection of the nail fold
with or without extension
deep to the nail
Run around

28. Clinical features
•On inspection-redness and swelling of nail fold.
•Excruciating/severe throbbing pain and tenderness(dependent throbbing)
•Visible pus under nail root-quantity 0.5ml
Treatment
•Pus is sent for culture and sensitivity.
•Antibiotics like cloxacillin,amoxicillin,flucloxacillin.
•Analgesics.
•Increasing vascularity of the part by alternating tying and releasing a thread starting
from the base of the finger up to the distal interphalangeal joint.

29. Operative Treatment
•It is required when abscess has developed.
•Pus is drained by lifting nail fold from nail till
proximal end of nail is reached .
•It is done under digital block-xylocaine2%
without adrenaline.
•If pus has spread beneath nail- proximal part of
nail is separated from its bed and cut across
with fine pointed but strong scissors.
•A simple dressing with penicillin tulle is
enough.

31. Chronic Paronychia
• It is commonly due to fungal infection-candida
• Affects women more often and those who do much washing.
Clinical features
• Onset is insidious.
• On inspection-eponychium is glazed and faintly pink (angry red in acute paron.)
• Nail may become cross-ridged and pigmented(nail is normal in acute paron.)
• Itching in nail bed
• Recurrent pain and discharge
• This condition may be multiple.(single lesion in acute paron.)

33. INVESTIGATION
•Culture of scrapings for fungal / bacterial causative organism.
TREATMENT
Preventive:
•wearing of rubber gloves at time of washing.
Curative:
•Indolent infection treated by diluted Bradosol solution in spirit in ratio of 1:500.
This should be dropped into nail fold twice daily.
•Nystatin ointment for anti-fungal.
•Soframycin ointment for anti-bacterial.
•Treatment to be continue till pockets are filled with granulation tissue.
•Hands to be kept as dry as possible for epithelialisation.
Operative treatment:
•whole nail may have to be removed

34. Apical Subungual Infection
• Arises due to prick beneath the tip of the nail,
• infection of the space between subungual epithelium and periosteum.
• Gradually small abscess develops at the tip of the finger just under the nail.
• It is exquisitely painful and very little swelling.
• Redness around abscess which extends along one or both lateral nail folds.
• There is extreme tenderness which is greatest just beneath free edge of the
nail.

35. Treatment
•Pus is drained – excising a small V-
shaped portion of the nail from centre of
its free edge.
•Excision of nail –include excision of full
thickness of the skin overlying the
abscess.
Complication
•Osteomyelitis - end of distal phalanx

36. Terminal Pulp space infectionFELON
• Second most common hand infection .
• Originates from a prick
• Index and thumb are most often affected.
Surgical anatomy
• It is a closed space as proximally the deep fascia is attached to thin skin of distal flexion crease and
fuses with the periosteum of the distal phalanx just distal to insertion of deep flexor tendon at level
of epiphyseal line.
• Pressure increases when there is infection ,compressing terminal artery – thrombosis-osteomyelitis
of terminal phalanx.
• The space is filled with compact fat which is subdivided into 15to 20 compartments.
• The strong proximal boundary of fascial compartment acts as an effective barrier to infection
spreading proximally to finger.

38. Clinical features
•Dull pain – worsens when hand hangs down.
•Pain increases at night interfering with sleep.
•Tenderness is exquisite.
•Pain becomes throbbing in nature with formation of pus.
•Fever
•Regional lymph nodes are enlarged and tender-axillary,epitrochlear
•Often suppuration is severe, forming collar stud abscess which eventually may burst.
Complication:
•Osteomyelitis of terminal phalanx.
•Pyogenic arthritis of distal interphalangeal joint.
•Spread of infection to the flexor tendon sheath,probably dude to wrong incision.
•Septicaemia.
Investigation
•X-Ray to rule out osteomyelitis
•Pus for culture and sensitivity.

39. Treatment
•Analgesics
•Antibiotics-flucloxacillin
Operative treatment
•Pus should be drained before disease involves the
bone.
•Short transverse incision is made on the most swollen,
prominent and tender spot.
•Deepened till pus is reached.
•For proper drainage portion of skin is required to be
excised.
•After opening ,pus is drained and wound is scraped.
•If necrosed bone is detected by X-Ray ,amputation is
done.
•The remaining bone is curetted.
•In children,regeneration of diaphysis is possible,if
periosteum remains undamaged.

40. Infection of middle volar space
• Fibrofatty tissue occupies this space – more loosely packed.
• Though the space is partitioned by flexion creases,yet abscess may spread into
proximal segment and web space.
• It is shut off from dorsal cellular space by fibrous septa extending from skin to
periosteum.
Clinical features
• Fingers become swollen at middle particularly – palmar aspect.
• Middle volar space becomes tender.
• Finger is held in semiflexion position.

41. Infection of proximal volar space
• Fibro fatty issue here is loosely packed.
• It communicates freely with corresponding web spaces.
Complications:
• Infection in these spaces tend to spread to- web space
-interphalangeal joint
-tendon sheath
Treatment
• Antibiotics
• Drainage of pus.
• If abscess has spread sidewise – longitudinal incision just in front of digital vessels.
• If pus is localised to palmar aspect- transverse incision.

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