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INFECTION, MIDPALMAR SPACE

Introduction

Infection of the midpalmar space is a rare, closed-space infection that may be difficult to diagnose. It is either a primary infection caused by direct bacterial inoculation or a secondary infection spread through adjacent areas. Flexor tendon sheath infections involving the long and ring fingers can spread into the midpalmar space.  Aggressive treatment that includes intravenous (IV) antibiotics, drainage, debridement and intraoperative irrigation is necessary to control and  prevent further spreading of the infection.1,2

Pathophysiology

  • Midpalmar space infections typically occur through bacterial inoculation after a penetrating trauma (primary), or a contiguous spread from adjacent flexor tendon sheaths (secondary)1
  • Streptococcus, Staphylococcus aureus and coliform organisms are the most common infectious agents3
  • In very rare cases, hematogenous seeding may be responsible for the infection3

Related Anatomy

  • The deep spaces of the hand include the midpalmar, thenar, hypothenar, dorsal subaponeurotic, Parona’s quadrilateral and interdigital subfascial web spaces1,2
  • The midpalmar space has been described as the most important space in the hand, and its anatomic extent has been well defined4
  • It is a trapezoidal space located deep to the flexor tendons of the long, ring and little fingers, and superficial to the 3rd-5th metacarpals; the midpalmar space is separated from the thenar space on the radial side by a very firm partition with a weaker proximal edge, and it is overlapped by the ulnar bursa on the ulnar side1
  • The midpalmar space contains the superficial palmar arch, flexor tendons, lumbrical muscles and digital nerves and vessels, and communicates with Parona’s space through the carpal tunnel2,5

Incidence and Related Conditions

  • Infections of the deep palmar spaces are generally considered uncommon6
  • Midpalmar space infections can invade the thenar space if persisting for more than 48 hours, and vice versa7
  • An abscess typically develops in the deep flexor tendons if both the midpalmar and thenar spaces are involved6

Differential Diagnosis

  • Infection of first web space
  • Infection of the long and/or ring flexor tendon sheaths
  • Infections of the radial and/or ulnar bursa
ICD-10 Codes

  • INFECTION, MIDPALMAR SPACE

    Diagnostic Guide Name

    INFECTION, MIDPALMAR SPACE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    INFECTION, THENAR, HYPOTHENAR, MIDPALMAR SPACE, CUTANEOUS ABSCESS L02.512L02.511 

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Midpalmar Space Infection
  • Midpalmar Space Infection: The midpalmar space is a potential space between the volar interosseous fascia, the flexor sheath, the oblique and hypothenar septum. Infection is usually secondary to spread of infection from flexor sheath of long and ring fingers.
    Midpalmar Space Infection: The midpalmar space is a potential space between the volar interosseous fascia, the flexor sheath, the oblique and hypothenar septum. Infection is usually secondary to spread of infection from flexor sheath of long and ring fingers.
  • Infections of the long finger flexor tendon sheath can spread into the midpalmar space.
    Infections of the long finger flexor tendon sheath can spread into the midpalmar space.
  • Infections of the ring finger flexor tendon sheath can spread into the midpalmar space.
    Infections of the ring finger flexor tendon sheath can spread into the midpalmar space.
  • Infections of the long and ring finger flexor tendon sheaths (arrows) can spread into the midpalmar space.
    Infections of the long and ring finger flexor tendon sheaths (arrows) can spread into the midpalmar space.
Symptoms
Swelling, redness, and tenderness on both sides of the hand with loss of concavity of the palm
Tension and bulging of the tough palmar skin
Finger rigidity with pain during any attempted extension of the long and ring fingers, referred to the middle of the palm
Typical History

This is an extremely rare diagnosis, but infection in the midpalmar space is most considered whenever the patient presents with signs of infection and severe palmar swelling and tenderness. The typical patient is likely to have either a long or ring finger flexor tendon sheath infection which has spread to the midpalmar space. In the antibiotic era, patients with midpalmar space infections are likely to either have a neglected finger infection, have diabetes, is immunocompromised and/or is a drug user.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Control the infection.
  • Stop the infection.
  • Maintain hand function by avoiding stiffness and fixed contractures.
Conservative
  • Close observation and IV antibiotics are imperative, but this must be accompanied by aggressive surgical intervention
  • Rehabilitation with passive assisted or active range of motion exercises should begin after the inflammation has subsided
Operative
  • Surgical drainage of the midpalmar space through a dorsal, palmar, or combined incision
    • A combined dorsal-palmar, two-incision approach is often preferred to ensure adequate drainage
    • An incision perpendicular to the first-web commissure that extends dorsally and palmarly may also be used
    • Care must be taken to avoid injury of the neurovascular bundle or contamination of the surrounding tissue
  • Midpalmar space debridement
  • Intraoperative irrigation
  • The decision for continuous postoperative irrigation should based on intraoperative findings
  • A second look incision and drainage maybe needed in these complex cases.
Complications
  • Spread of infection to adjacent sheaths, nerves, bones and/or joints
  • Decreased active range of motion particularly in the long and ring fingers.
  • Contractures 
Outcomes
  • Unless midpalmar space infections are diagnosed early and treated swiftly with appropriate antibiotics and adequate surgical treatment, the prognosis for normal hand function will be guarded.
Key Educational Points
  • Despite several advancements in diagnostic and management tools, midpalmar space and other hand infections continue to present a clinical challenge
  • A midpalmar space infection is an abscess requiring surgical incision and drainage and will NOT be controlled by IV antibiotics alone.
References

Cited

  1. Rigopoulos N, Dailiana ZH, Varitimidis S, Malizos KN. Closed-space hand infections: diagnostic and treatment considerations. Orthop Rev (Pavia) 2012;4(2):e19. PMID: 22802987
  2. Abrams RA, Botte MJ. Hand Infections: Treatment Recommendations for Specific Types. J Am Acad Orthop Surg 1996;4(4):219-230. PMID: 10795057
  3. Hausman MR, Lisser SP. Hand infections. Orthop Clin North Am 1992;23:171-185. PMID: 1729665
  4. Kanavel AB: The symptoms, signs, and diagnosis of tenosynovitis and major fascial space abscesses. In Kanavel A, ed: Infections of the Hand, 6th Edition. Philadelphia, PA, Lea and Febiger 1933, pp 33-4.
  5. Tubiana R, Gilbert A, Masquelet A, Dunitz M. An Atlas of Surgical Techniques of the Hand and Wrist. London, England: Lippincott Williams & Wilkins; 1999.
  6. Robins RH. Infections of the hand. J Bone Joint Surg Br 1952;34-B(4):567-80. PMID: 12999946
  7. Beye HL. Deep palmar hand infections: a clinical study of the diagnosis and treatment of these conditions. Ann Surg 1918;67(2):152-62. PMID: 17863851

Reviews

  1. Rigopoulos N, Dailiana ZH, Varitimidis S, Malizos KN. Closed-space hand infections: diagnostic and treatment considerations. Orthop Rev (Pavia) 2012;4(2):e19. PMID: 22802987
  2. Abrams RA, Botte MJ. Hand Infections: Treatment Recommendations for Specific Types. J Am Acad Orthop Surg 1996;4(4):219-230. PMID: 10795057

Classics

  1. Beye HL. Deep palmar hand infections: a clinical study of the diagnosis and treatment of these conditions. Ann Surg 1918;67(2):152-62. PMID: 17863851
  2. Kanavel AB: The symptoms, signs, and diagnosis of tenosynovitis and major fascial space abscesses. In Kanavel A, ed: Infections of the Hand, 6th Edition. Philadelphia, PA, Lea and Febiger 1933, pp 33-4.
  3. Robins RH. Infections of the hand. J Bone Joint Surg Br 1952;34-B(4):567-80. PMID: 12999946
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