Carpal tunnel

&Spaces of hand
Dr. O.E. YAMA

MBBS, M.Sc., Ph.D. PGA.ART

(Department of Anatomy
CMUL)

Carpal Tunnel

Carpal tunnel & structures at the wrist

The carpal tunnel is formed anteriorly

at the wrist by a deep arch formed by the

carpal bones & the flexor retinaculum.

Carpal arch
Base of carpal arch is formed:
Medially by the Pisiform & hook of Hamate &
Laterally by the tubercles of the Scaphoid &
Trapezium.

She Likes To Play

1.Scaph

2.
Lunate

boat)
Carpals
Mnemonic

(Inthe
3.
moonlight)
Triquetru

oid(A

(ThethirdT
Bone)
Pisifor4.

m
8.
(Pea
Hamat
shaped)
e

5.Trapez
ium
6.
bythe
Trapezoid
thumb

(Isbyits
side)

Try To Catch Her

(A
hambone
7.Capit
Witha
atehook)

Flexor retinaculum
Is a thick connective tissue

ligament that bridges the space

btw medial & lateral sides of the
base of the arch & converts the
carpal arch into a carpal tunnel.

Structure & relations

1. Four tendons

of the flexor
digitorum
profundus
2. Four tendons
of the flexor
digitorum
superficialis
3. One tendon of
the flexor
pollicis longus
4. Median nerve

Carpal tunnel syndrome

Carpal tunnel syndrome is an

entrapment syndrome caused

by pressure on the median
nerve within the carpal tunnel.
Signs & Symptoms:
Tingling & Numbness in the fingers
Aching in the thumb
Burning pain from wrist to the fingers
Change in touch or temperature
sensation
Clumsiness in hands
Weakness of grip, ability to pinch &
other thumb actions
Swelling of hand & forearm
Change in sweat functions of hand

CTS is a clinical diagnosis

Sensory examination

Abnormalities in sensory
modalities may be present on
the palmar aspect of the first 3
digits & radial one half of the
fourth digit

Motor examination

Wasting & weakness of the

median-innervated hand
muscles (LOAF muscles) may
be detectable.
L 1st & 2nd lumbricals
O - Opponens pollicis
A - Abductor pollicis brevis
F - Flexor pollicis brevis

Causes of Carpal Tunnel

Syndrome
In most cases, the cause is
unknown, but it is associated
with many different factors:
Demographic: Increasing age,

Female sex, Dominant hand,

Race (white)
Genetic : Square wrist,
Thickened transverse ligament,
Short stature
Medical Condition : Diabetes,
Thyroid disease, Hereditary
neuropathy, Arthritis
Occupation : Due to repetitive
movement: Common in computer
professionals. Due to constant
dorsiflexion of wrist while typing
the keyboard
Injury or trauma
Pregnancy

Spaces of hand

Arrangement of the fascia & fascial septae

in the hand is such that they form many

spaces.
Fascial spaces of the palm are potential
spaces filled with loose connective tissue.
Spaces are of surgical importance because
they may become infected & distended with
pus.

Hand
1. Forearm:
a) Space of Parona
2. Hand:
b) Palmar spaces: Thenar, Midpalmar &
Web spaces
c) Dorsal spaces: Dorsal subcutaneous &
Dorsal subaponeurotic spaces
d) Superficial Pulp space of fingers
e) Radial & Ulnar bursae

A.) Space of Parona

Space of Parona
Located in forearm
Is a potential space btw:
Flexor pollicis longus (FPL)
tendon, Flexor digitorum
profundus (FDP) tendons
(anterior boundary) &
Pronator quadratus (posterior
boundary)

Continuous with Palmar

space thro flexor tendons &

thro carpal tunnel

B.) Palmar Spaces

1. Thenar space
2. Midpalmar
space
3. Web spaces

Thenar Space
It is a triangular shaped space
Boundaries:
Anterior: Palmar aponeurosis, Thenar muscles, long flexor
tendon of index finger & 2nd lumbrical muscles
Posterior: fascia covering adductor pollicis
Lateral: Lateral palmar septum with tendon of flexor pollicis
longus
Medial: Intermediate/mid palmar septum

It extends proximally from distal border of flexor

retinaculum to distally space btw fingers on both side

of index finger.
Contains: Tendons of FPL, FDS&P to index finger,
palmar digital nerves & vessels to thumb & radial side
of index finger.

Midpalmar Space
It is triangular shaped space
Boundaries:
Anterior: Palmar aponeurosis,

flexor tendons of medial 3 digits

covered in ulnar bursa & medial 3
lumbricals
Posterior: Fascia covering 3rd & 4th
interossei & metacarpal bones
Medial: Medial Palmar septum
covering hypothenar muscles
Lateral: Mid-palmar septum
Proximally it extends from distal
margin of flexor retinaculum to
distally up to the space of fingers btw
3rd & 4th fingers.
Contains: 3-5 flexor tendons, 2-4
lumbricals, superficial palmar arch,
3-5 digital vessels & nerves.
Communicates: subcutaneous
tissues at webs & extends dorsal to
common flexor sheaths.

Web Spaces
Is the soft tissue btw

bases of fingers
There are 4
Subcutaneous spaces
From its free margin, it
extends to level of MCP
joint.
Contents:
Subcutaneous fat,
Superficial transverse

metacarpal ligament,
Interosseous & lumbrical
tendons,
Digital nerves & vessels.

C.) Dorsal Spaces of hand

1. Dorsal subcutaneous
space &
2. Dorsal subaponeurotic
space

a. Dorsal subcutaneous space:

It lies immediately deep to the loose skin of the dorsum
of the hand.
In subcutaneous infections, the pus points through
the skin & can be drained at the pointing site.
b. Dorsal subtendinous space:
This space lies btw the metacarpal bones & the
extensor tendons which are united to one another by a
thin aponeurosis.
In subtendinous infection, the pus points either at
the webs or at the borders of the
hand
& can be
Both
of these
drained accordingly.
spaces are
triangular in Shape
with bases at the
knuckles & apex at
the wrist

D.) Superficial Pulp Space

of Fingers

Superficial Pulp Space

The deep fascia of pulp of each

finger fuses with Periosteum

of the terminal phalanx just
distal to the insertion of long
flexor tendons & closes off a
facial compartment known as
the pulp space which is
subdivided by numerous
Fibrous septa, passing from the
deep fascia to the periosteum.
The terminal branches of
digital artery that supplies the
diaphysis of terminal phalanx
runs thro the pulp space filled
with fat.
The pulp space is limited
proximally by firm adherence
of skin & the distal flexion
crease to the underlying tissue;
this prevents pulp infection
from spreading proximally
along the finger.

E.) Radial & Ulnar bursae

Radial Bursa
The synovial sheath of

tendon of Flexor pollicis

longus (radial bursa).
This sheath is usually
separate but may be
communicate with the
common sheath behind the
retinaculum
Superiorly, it is coextensive
with the common sheath &
inferiorly it extends up to
the distal phalanx of thumb
Radial bursa communicate
with ulnar bursa at the level
of wrist in about 50% of
subj.

Ulnar Bursa
Common flexor synovial sheath (Ulnar

bursa)
The long flexor tendons of the fingers
(flexor digitorum superficialis &
profundus), are enclosed in a common
synovial sheath while passing deep to
the flexor retinaculum.
The sheath has a parietal layer lining
the walls of the carpal tunnel, & a
visceral layer closely applied to the
tendons.
Lateral side ends in the middle of palm
in a blind diverticula around the
tendons to the index, middle, & ring
fingers.
Medial side is prolonged on the
tendons to little finger

1. Paronychia:
1. Infection along lateral nail fold.
2. Follows trauma of nail bed.
2. Felon (Pulp-Space Infection)
1. Most common hand infection
2. Subcutaneous abscess in pulp space of finger cause

3.
4.
5.
6.
7.
8.

throbbing pain.
3. Pressure on the blood vessels could result in necrosis of
the diaphysis.
4. Epiphysis of this bone is saved because it receives its
arterial supply just proximal to the pulp space.
Infection of MidPalmar Space:
1. Infection reaches from a lumbrical canal or infected
tendon sheath.
Infection of Thenar Space:
1. Lies under palmar fascia.
2. Bounded dorsally by transverse head of adductor
pollicis.
Web Space Infection:
1. Most common site after involvement of pulp spaces.
2. Pus mostly gathers near palmar space but may spread.
Infection of Radial 0r Ulnar Bursa:
1. May spread to radial bursa.
Infection of Dorsum of Hand:
1. Dorsum swells but pus seldom collects.
2. If pus collects it is subcutaneous.
Pyogenic Flexor Tenosynovitis:
1. Closed space infection in of flexor tendon sheath of
digit.
2. Results from penetrating trauma or hematogenous
spreading.