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 3 rd & 4 th 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 2 nd, 3 rd & 4 th 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 4/5 th of distal phalanx may happen If whitlow is not treated Why Blood supply is from the branches arising within this space Proximal 1/5 th 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 1 st dorsal metacarpal From radial 2 nd, 3 rd, & 4 th 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