The Infected HandA Survey of Selected Conditions

Jeremy Webb, MS4 WFUSOM

Topics at HandInitial Evaluation and Treatment

Cellulitis

Paronychia/Eponychia

Felon

Septic Flexor Tenosynovitis

Deep Space Infections

Fight Bite

Herpetic Whitlow

Initial EvaluationHistory

Timing, Pain, Loss of fxn, Drainage, FeverSource, Hx of trauma, Predisposition, FBs

Tetanus Status

PhysicalExposure, Observation, Palpation, ROM, Sensation,

LAD, Lymphangitis

TestingRadiographs, Gram Stain, Cx

Conservative Treatment

RestWarm Soaks

ElevationFunctional Immobilization

Anti-inflammatory/AnalgesicsPO Antibiotics for Associated Cellulitis

Tetanus PPXClose Follow Up

Organisms/Antibiotics

Secondary to Minor Trauma

Commonly Gram Positive Organisms

Broad Initial Rx Therapy Directed

Tx for MRSA if indicated

Cellulitis

Physical Exam

Erythema

Swelling

Pain

Occasional LAD

Lymphangitis

Treatment

Conservative Therapy

Parenteral Antibiotics If: extensive/circumferential involvement, ascending lymphangitis, rapid spread,

immunocompromised

Paronychia

Treatment

No Fluctuance: Conservative Therapy

Fluctuance: Drainage Necessary

Felon

Signs and Symptoms

Throbbing Pain Poor Sleep

Red, Tender Pulp Space

Spontaneous Drainage

Necrosis if Delay in Dx

Treatment

Septic Flexor Tenosynovitis

Classic Signs and Symptoms

Tenderness over flexor tendon sheath

Symmetric swelling of the finger (index, middle, ring)

Pain with passive extension (most constant)

Flexed posture of involved digit at rest

Special Note

Recent Hx of STD Suspect Disseminated Neisseria gonorrhoeae

Treatment

Early Infection (<48 hrs): Parenteral ABX

Failure to Respond/Delayed Presentation: Surgical Management

Deep Space Infections

Physical Exam

Palpate Volar Surface: tenderness, induration, fluctuance

Sensory Evaluation

ROM

Beware Collar Button Abscess

Treatment

Parenteral Antibiotics

Surgical Drainage

Fight Bite

Fight Bite

Inoculation from opponent’s teeth

May lead to serious infection

Variety of organisms including staph, strep, anaerobes, and Eikenella corrodens

Work Up/Treatment

MUST inspect carefully to r/o deep injury

Examine extensor tendon fxn and look for loss of knuckle height

Radiographs mandatory: fx, tooth FB, air in joint space

Broad spectrum antibiotics

Herpetic Whitlow

History is Crucial

Commonly misdiagnosed as felon or paronychia

I & D is contraindicated, and may worsen condition

Time Course

Prodromal Phase Burning pain 24-72 hours prior to development of

skin changes

EruptionSkin changes over 2 weeks, including erythema,

vesicular formation

Resolution

Treatment

Conservative Management

Do not I & D unless secondary bacterial infection

Acyclovir in severe cases or immunocompromised populations

The End