HAND INFECTIONS

OVERVIEWAetiology :- Who? manual workers & house-wives

- 90 % Staphylococcus aureus Polymicrobial infections, Gram-negative organisms and anaerobic bacteria are documented

- Mode of entry minor inj. & punctures

OVERVIEW(CONT.)C/P “in general” :- Pain, swelling & fever .- Site according to point of max. tenderness rather than area of oedema !

Investigations:- Plain X-ray if F.B. is suspected- Bl. Sugar testing in recurrent infections

OVERVIEW(CONT.) Treatment : (Generally)1- Antibiotics are immediately started e.g.

Flucloxacillin, erythromycin, amoxycillin clavulinic acid & 1st and 2nd generations of cephalosporins. Gentamicin is added when there is a history of injected drug use.

2- Elevation & if needed, immobilization in position of function

3- Suppuration or No response to one day intensive antibiotic therapy Drainage of pus. Drainage releases pus and improves the venous return by decompressing the tension.

OVERVIEW(CONT.)- Acute paronychia or Felon local ring

anaethesia (without adrenaline) , general anaethesia is preferred

- Tourniquet & Elevation Bloodless field- Appropriate skin incisions & sinus forceps- C & S- Soft rubber drains e.g. piece of surgical

glove* Post-op. Elevation, Physiotherapy &

Dressing

CLASSIFICATION [I] Cutanous & sub-cutanous infections:- Paronychia- Pulp Space Infection (Felon)- Web Space Abscess [II] Fascial spaces infection : Deep Space Infection i.e. midpalmar space,

thenar space and Parona’s space. [III] Infection of the tendon with its

synovial sheath “tenosynovitis”. [IV] infection of the bone & joint

(septic arthritis). [V] miscellaneous infections.

SKIN INFECTIONS

Cellulitis and Lymphangitis

PARONYCHIA

Anatomy

PARONYCHIA (ACUTE) Most common infection in the hand

Localized superficial infection or abcess of the lateral nail fold

Typically is due to superficial trauma (e.g. hangnails, nail biting, dishwashing).

Paronychia in children often is the result of finger sucking

PARONYCHIA (TREATMENT)Early Cellulitis

Soaks, elevation, antibioticsFluctuant – all of the above, plus…

DrainMay need anesthesia (digital block)Soften by soakingIf severe infection with purulent drainage beneath nail, requires removal of a portion of the nail

Follow up 24-48 h.Most resolve in 5-10 days

PARONYCHIA INCISION AND DRAINAGE

OPERATIVE METHODS

(A) Elevation of the eponychial fold with flat probe to expose the base of the nail. (B) Placement of an incision to drain the paronychium and to elevate the eponychial fold for excision of the proximal one-third of the nail. (C-E) Incisions and procedure for elevating the entire eponychial fold with excision of the proximal one-third of the nail. A gauze pack prevents premature closure of the cavity.

A MODERATE PARONYCHIA. SWELLING AND REDNESS AROUND THE EDGE OF THE NAIL IS CAUSED BY A LARGE

PUS COLLECTION UNDER THE SKIN.

 ANOTHER VIEW OF THE SAME PARONYCHIA. THE MAJORITY OF THE SWELLING AND REDNESS CAN BE

SEEN ON THE RIGHT SIDE OF THIS PICTURE.

A SCALPEL (KNIFE) IS INSERTED UNDER THE SKIN AT THE EDGE OF NAIL TO OPEN THE PUS

POCKET AND DRAIN IT TO RELIEVE THE PRESSURE AND TREAT THE INFECTION.

 A CLOSER VIEW OF THE SCALPEL USED TO OPEN THE INFECTED AREA.

 THE DOCTOR PUSHES ON THE SWOLLEN AREA TO GET THE PUS OUT AFTER THE INCISION

WAS MADE WITH THE SCALPEL.

CHRONIC PARONYCHIA

Chronic Paronychia of the Left Thumb

  

Recurrent paronychia in the left index with inflammation of the nail folds. Recurrent or chronic paronychia may be a sign of poor peripheral circulation or lowered general resistance.

PULP SPACE INFECTION (FELON)

Anatomy :The distal palmar phalanx is

compartmentalized by tangentially oriented fibrous septa, resulting in a closed compartment at the distal phalanx, which helps prevent the proximal spread of infection.

Mode of infection : Infection typically is due to direct

inoculation of bacteria by penetrating trauma but may be caused by hematogenous spread and by local spread from an untreated paronychia.

PULP SPACE INFECTION (CONT.) Paronychia may be present and/or it may

be a progression from paronychia C/P & Complications :

“Don’t wait for fluctuation”-Infection results in edema and increased

pressure within the closed compartment. This can impair venous outflow and lead to a local compartment syndrome

- Invasion of the bone leads to osteomyelitis

PULP SPACE INFECTIONS (FELON)

Distal pulp space infection of the right thumb (arrow) ‘Felon’, an early case, with three days of increasing throbbing pain.

OPERATIVE METHODS

The best is a longitudinal incision over the area of greatest fluctuance.

To avoid penetration of the tendon sheath, the incision should not extend to the distal interphalangeal crease.

HERPETIC WHITLOWHerpes simplex virus (HSV) infection of the distal finger typically results from direct inoculation of the virus into broken skin. Infection by type 1 or type 2 HSV is clinically indistinguishable. As in herpes infections elsewhere in the body, it is believed that the virus can remain dormant in the neural ganglia, leading to recurrent infections.

Herpetic whitlow in an infant with concomitant primary herpes simplex virus (HSV)

gingivostomatitis.

HERPETIC WHITLOW C/P

Incision is contraindicated as it spreads the infection, unroofing

relieves the painGenital herpes in self or partner, Health

care workers and Children with gingivostomatitis

Symptoms: Localized pain, pruritus, and swelling

followed by the appearance of clear vesicles

Typically localized to 1 finger only (symptoms involving more than 1 finger are more typical of coxsackievirus infection)

HERPETIC WHITLOW C/P (CONT.)

Clear vesicles on an erythematous border localized to 1 finger

Pain, typically out of proportion to findings Edema Turbid or cloudy fluid in vesicles possibly

suggesting a superimposed pyogenic infection

In later stages, coalescence of vesicles to form an ulcer

Distal finger pulp remains soft, distinguishes HSV infections from bacterial felon

Treatment is by dry gauze dressing

DEEP SPACE INFECTION

These are infections in the potential deep spaces of the hand, i.e. midpalmar space, thenar space and Parona’s space.

Parona’s space is deep in the distal forearm between the pronator quadratus muscle and the flexor digitorum profundus tendons. This space is contiguous with the radial bursa, ulnar bursa and midpalmar space.

Infections in these spaces may follow haematogenous spread, penetrating injury or rupture of pus from a flexor tendon sheath.

FLEXOR TENDON SHEATH INFECTION

PARONA’S SPACE INFECTION

usually results from spread of infection from the adjacent and contiguous midpalmar space, or from the radial or ulnar bursae. A flexor tendon sheath infection may extend proximally to involve the bursae and Parona’s space.

There is swelling, tenderness, and occasionally fluctuance of the distal volar forearm. Digital flexion may be painful.

DEEP SPACES OF THE HAND

DEEP SPACE INFECTION (C/P)

In midpalmar space infections, the hand loses its normal palmar concavity with tenderness and induration over the palm. There is dorsal hand swelling and limited and painful motion of the middle and ring fingers.

In thenar space infections, the thenar region is dramatically swollen and exquisitely tender. The thumb is abducted due to the increased pressure and volume in the thenar space. Motion of the thumb and index finger is painful.

THENAR SPACE INFECTIONS

Thenar space infection. Four days after a puncture wound of the thenar crease there is pain, tenderness, swelling and restricted movement. The mid-palmar space was also involved.

OPERATIVE METHODS (A) Volar transverse approach to the thenar space. Nerve injury is a potential complication. (B) Thenar crease approach. Nerve injury can result from this approach. It has the added disadvantage of limited drainage of the space behind the adductor pollicis. (C) Dorsal transverse approach. A contracture of the web space can result if this incision is placed too close to the edge of the web. (D) Dorsal longitudinal approach to the thenar space.

MIDPALMAR SPACE INFECTIONS

Collar stud abscess resulting from stabbing of the thenar crease with an indelible pencil. The deep component of this abscess was in the midpalmar space which became tender and swollen. The middle finger is flexed because of involvement of its tendon sheath.

OPERATIVE METHODS

(A) Transverse distal palmar exposure of the midpalmar space. (B) Approach to the midpalmar space through the lumbrical canal. (C) Combined longitudinal and transverse approach. (D) Longitudinal approach to the midpalmar space.

HYPOTHENAR SPACE INFECTIONS

Approach to the hypothenar space

WEB SPACE “COLLAR BUTTON” ABSCESS

A dorsal thenar web space infection

OPERATIVE METHODS

(A) Curved longitudinal volar incision for drainage of a web , (B) Dorsal incision used in conjunction with A. (C) Volar transverse incision, can cause web space contracture. (D) Volar exposure, used with dorsal incision B.

DORSAL SPACE INFECTIONS

Fig. : Dorsal subcutaneous space infection following a bite over the metacarpo-phalangeal joint of the ring finger. There is extensive dorsal swelling.

Fig. : A deep dorsal (subaponeurotic) space infection in an elderly diabetic. This abscess burst spontaneously and discharged foul smelling pus.

PYOGENIC FLEXOR TENOSYNOVITIS

Fig. : Testing for local tenderness over the proximal end of the flexor tendon sheath with a probe or swab stick.

Fig. : Testing passive extension of the fingers. The hand rests on a table and gentle passive pressure is applied to the fingernail. In a patient with septic tenosynovitis such minimal movement of the flexor sheath produces exquisite pain.

OPERATIVE METHODS

Incisions for drainage of tendon sheath infections. (A) Open drainage incisions. (B) Single incision for instillation therapy of tendon sheath infection. (C) Sheath irrigated via needle proximally and single distal incision. (D) Incisions for through-and-through intermittent irrigation. (E) Closed tendon sheath irrigation technique. (F) Closed irrigation of ulnar bursa.

ULNAR AND RADIAL BURSA INFECTION

The radial bursa is a continuation of the flexor pollicis longus tendon sheath through the flexor retinaculum to a level 2.5 cm above the wrist joint.

The ulna bursa arises from the sheath of the fifth digit and joins the common flexor sheath at the wrist. It too passes through the flexor retinaculum to end 2.5 cm above the wrist.

Hence ,infection of both 'bursa' may result from direct spread proximally along the associated tendon sheath or from a penetrating injury.

Treatment is similar to that recommended for tendon infections: open or closed irrigation, leaving a drain in situ and antibiotic cover

OSTEOMYELITIS

Fig. : Acute osteomyelitis. Five weeks after penetration and infection of the lateral pulp space, the thumb pulp remained painful, tender and slightly swollen.

 

Fig. : X-ray rarefaction of the distal phalanx.

PYOGENIC ARTHRITIS

Septic arthritis occurring three weeks after a bite wound to the dorsal aspect of the proximal interphalangeal joint. The finger became increasingly painful until pus discharged. Bite wounds are often complicated by severe infection.

CHRONIC INFECTIONS

Atypical Mycobacterial infections Tuberculosis Leprosy Fungal infections Viral infections Algal, protozoan, and parasitic infections

COMPLICATIONS OF HAND INFECTIONS

1- Necrosis of Tendons 2- Skin Loss3- Secondary Haemorhage4- Persistent Oedema5- Lymphangitis6- Stiffness, Ankylosis and Contractures7- Osteomyelitis and Septic Arthritis