Seminar on hand infection and

management
Presenter :Seid hussen (GSR-II)
Moderator :Dr abiy (Orthopedics surgeon)
febuary 2015 E.C
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 Outlines

•Introduction
•Patient approach
•Superficial hand infection
– Paronychia
– Felon
– Herpetic whitlow
– Pyogenic flexor tenosynovitis
•Deep hand infection
• subaponerotic
• Thenar
• Hypothenal
• midpalmar
•References 2
 INTRODUCTION

• Etiology of hand infections are diverse

– most are due to direct inoculation of bacteria from
penetrating trauma and lacerations
• Evaluation and management is based on anatomic location
– fingertip, finger, hand,
– wrist, joints and bone
• Management involves multidisciplinary team
• Infection mimickers should have to be considered

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 Patient approach
• History  — A focused
-medical history possible source of infection,
-progress of the infection,
-the immune status of the patient,
. Prior injury: Any prior hand injury from splinters, bites,
needle sticks,
• Hand dominance: The patient’s dominant hand should be
documented.
• Occupation : The patient’s occupation may increase his or
her exposure to certain infectious agents (chronic
paronychia
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Symptoms : -The onset of pain
-loss of function,
-fever and/or chills.
•Severe throbbing pain is suggestive of an
abscess in a confined space

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 Clinical examination
•   Vital signs should be recorded.
• The entire upper extremity should be exposed.
• examined for the presence of swelling,
deformity, open wounds, alignment of the fingers,
neurovascular status, and local tenderness.
• Fluctuance.
• Skin necrosis
• Tenderness and limited movement

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 Imaging
• Plain films  —  should be obtained when
indicated by clinical findings and history
• Foreign bodies: serve as a nidus of infection
• Fracture
• Periosteal elevation -nonspecific reaction to
tumor, infection, trauma, certain drugs, and
some arthritic conditions
• Gas in the soft tissues -Gas in soft tissue is
seen in type I necrotizing fasciitis
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 Paronychia
• Skin infection around the nail
• Most common hand infection
• Accounts for 30% of all hand infections
• Most commonly caused by Staphylococcus aureus
– followed by Streptococcus and Pseudomonas
• Originates from either proximal nail fold or
paronychium
• Infection typically begins unilaterally or just proximal
to nail
• Can spread deep between nail plate and nail bed

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 Clinical presentation of Paronychia
• Usually begins at one corner of the horny nail
• Travels under either the eponychium or the nail toward
the opposite side.
• Early presentations are
pain, redness, and swelling
• As it progresses gross purulence may collect around or
deep to nail plate
• Extension toward palmar fingertip may result in felon
• left untreated can expand around nail, “runaround”
infection
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. patient may have an acute paronychia of the
lateral nail fold in addition to an acute infection of
the eponychium.

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 Treatment of paronychia
 At early stage before developing abscess treatment is
oral antibiotics and warm soapy soaks
• An anti staphylococcal agent such as dicloxacillin (250
mg four times daily) or cephalexin (500 mg three to
four times daily) is appropriate in areas with a low
prevalence of MRSA
• In areas with a high prevalence of MRSA, an oral agent
likely to cover local strains of MRSA (eg, TMP-SMX
two double-strength tablets twice daily) is a reasonable
• For patients with a digit that has been exposed to oral
flora (nail biting, finger sucking
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• Once abscess is developed drainage is required
• Small abscesses can be unroofed and cultured
• Proper surgical decompression is required for large abscess
– Use digital block and digit tourniquet
– Elevate involved proximal or lateral nail fold from nail
plate
– If purulence has accumulated deep to nail plate remove
part of nail
• Incisions are made parallel to lateral nail folds
• If proximal nail fold is involved transverse incision over
the abscess can be made
• Continous soapy water soaks twice a day is needed until
wounds are sealed and dry
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• (A) The nail plate and eponychial
fold are elevated with a Freer elevator.
• (B) A skin incision is placed parallel
to the lateral nail fold to drain the
paronychia.
• (C) If proximal extension is needed,
the incision can be carried from the
corner of the nail fold and extended
laterally at an angle.
• (D) A second skin incision can be
performed to adequate drain the
paronychia.
• (E) Wicking the incision site with
gauze is recommended to prevent
premature closure and re-collection of
pus.

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 chronic paronychia
• Found in patients with prolonged exposure of
fingertips to a wet environment
• Presentation should have to be at least 6 weeks
• Candida albicans is primary pathogen responsible
• May involve multiple fingertips
• Presentations are
thickened, indurated, and erythematous tissue
proximal to nail plate
Nail plates may become thickened and discolored
eponychial fold may retract
Pain is less impressive than acute paronychia 14
 Treatment of Chronic paronychia

• Usually surgical but a trial of topical antifungal cream

or oral antifungal medication may be attempted
• Eponychial marsupialization is surgical treatment
– Use digital block and tourniquet
– 3–5 mm crescent-shaped portion of skin is
removed1 mm proximal to eponychial fold
– Leave roof of germinal matrix intact
– Remove deformed nail plate to reduce recurrence
– Change Soft gauze dressings once or twice a day
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E PONYCHIAL MARSUPIALIZATION

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 Herpetic whitlow
• Viral infection caused by HSV type 1 (60%) or 2 (40% )
• Invades dermis and subcutaneous tissue
• Symptoms begin 2–14 days after exposure
– painful, burning or tingling sensation of affected digit
disproportionate to the clinical findings
– Then erythema, edema and 1–3 mm grouped vesicles
over next 7–10 days
– Characterized by primary infection followed by latent
period
– Where virus enters cutaneous nerve endings and
migrates to peripheral ganglia
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 Cont’d

• Usually self-limiting with resolution within 3 weeks

• Physiologic or psychological stress, fever, and sun
exposure can induce recurrence
• vesicles unroofing can aid for definitive diagnosis
– with culture and Tzanck smear
– Avoid deep debridement as it can lead to
secondary infection and more dissemination

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 The treatment of herpetic whitlow
• is conservative (rest, elevation, and antiinflammatory
agents).
• Topical acyclovir has not been shown to be effective in
treatment.
• Surgery is contraindicated because it will spread the
infection into healthy tissue and may result in secondary
bacterial infection.
• does not require use of antibiotics unless a secondary
bacterial infection is suspected

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 Pulp space infections
•  The digital pulp, divided into multiple
compartments by fibrous septae that provide
structural support
• 15 to 20 percent of all hand infections
• thumb and index finger are the most commonly
affected digits
• results in increased pressure and can lead to
ischemic necrosis of surrounding tissue,
osteomyelitis, flexor tenosynovitis, or septic
arthritis of the DIPJ 20
• Staphylococcus aureus is most common causative
organism
• Can also be caused by community acquired MRSA
• Behaves like a deep space infection forming an abscess
– As it is confined within fibrous septa of pulp space
• usually follow penetrating trauma to fingertip
• Clinical presentation:
painful swollen fingertips which is exquisitely
tender over pulp space
Pain is confined distal to DIP flexion crease
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 Treatments of felon
• A very early presentation ,may be treated with warm
soaks, rest, elevation, and oral antibiotics.
• Antibiotic treatment is typically given for 5 days after
surgical drainage and for 7-10 days without drainage
• However, most patients with a pulp abscess require
surgical intervention.
• A simple incision and drainage procedure may provide
temporary relief;
• it is better to debride the abscess cavity in the operating
room because the infection may be more extensive than
the symptoms and clinical appearance suggest
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• (A) Cross section of the distal
figertip,showing inflmmation and
collection of flid within the septa.
(B) A unilateral midlateral incision
allows access to the septations of
the distal pulp.
• Care needs to be taken to avoid
the neurovascular bundles.
• (C) A single volar incision can be
used. This approach has less risk to
the digital neurovascular bundles.
• To avoid scar contracture, the
incision should not pass the flxion
crease

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Panel A depicts the incisions
used to drain a pulp abscess.
Left: Lateral incision.
Right: Palmar incision.
Panel B illustrates the surgical
approach to the pulp abscess
cavity.
The lateral incision enters the
abscess cavity dorsal to the
neurovascular bundle and
palmar to the palmar cortex of
the distal phalanx. The palmar
incision enters the abscess
cavity directly from the palmar
aspect.

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 Subcutaneous abscess
•  usually the result of minor penetrating trauma
that was neglected.
• A subcutaneous abscess of the finger presents
with localized swelling, erythema, and restricted
motion at the adjacent joints
• The digit is usually in a flexed posture.
• can occur on either the palmar or dorsal aspects of
the hand

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 Abscesses of the palmar skin
 are typically localized because the fibrous septae
anchoring palmar skin limit the spread of infection
 present with erythema and mild swelling on both
the palmar and dorsal aspects of the hand.
Palpation of the tendon sheath proximal and distal
to a palmar subcutaneous abscess will help
differentiate it from pyogenic flexor tenosynovitis
that is confined along the path of the tendon sheath.

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 In contrast, the dorsal skin of the hand ,
is loosely anchored to the underlying tissue,
 allows the spread of infection into potential
spaces:,
 the dorsal subaponeurotic space, which is deep to the
extensor tendons
A subcutaneous abscess of the dorsum of the
hand is associated with significant dorsal hand
swelling, a tender fluctuant mass, and pain with
extension of the finger

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(A) Palmar digital
subcutaneous
abscess.
(B) Dorsal digital
subcutaneous
abscess.
(C) Lateral digital
subcutaneous
abscess.

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 web space abscess
•  is a subcutaneous abscess involving the web space
• infection may be present on the palmar and dorsal
aspects simultaneously.
• It is also known as a collar button abscess because
of its resemblance to buttons used on dress shirts in
the early nineteenth century.
• usually results from a penetrating injury or a fissure
in the web space.
• patient presents with pain and swelling limited to
the web space and distal palm.
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• There may be greater swelling on the dorsal
aspect of the web, although the primary focus of
infection is on the palmar side.
• The adjacent fingers are usually in an abducted
position, and this may help differentiate it from a
pure dorsal or palmar subcutaneous abscess,
where the fingers are in the normal adducted
position.
• A web space abscess requires a combined palmar
and dorsal surgical approach for adequate
drainage and debridement
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-Must drain both dorsal
and
volar aspects of abscess;
-avoid webspace
incisions to prevent
contracture

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Pyogenic flexor tenosynovitis

-seven synovial
sheath,
-five for each
digit,
-a radial and an
ulnar bursa.

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• Flexor tendon sheath is closed system created
between
– two mesothelium-lined layers of visceral &
parietal layer which envelop flexor tendons
• Flexor tendon sheaths of thumb and small finger
communicate with
– radial and ulnar bursae, respectively
– which extend into carpal tunnel and space of
Parona
– In 80% of individuals radial and ulnar bursae
communicate 37
• Occurs when bacteria is inoculated into synovial
sheath commonly from penetrating trauma
• This causes increased pressure and disruption of
vascular supply within sheath
• Infection can travel throughout hand and forearm
• It is surgical emergency
• Horseshoe abscess can happen in case of radial
and ulnar bursae communication

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 Clinical presentation

• Kanavel’s cardinal signs

– tenderness over course of tendon sheath
– flexed posture of finger
– excruciating pain on passive extension of finger
– fusiform swelling of finger
• Disproportionate pain on passive extension is
most sensitive clinical sign

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 Treatments
• Under ideal circumstances, flid should be obtained from
the sheath for Gram stain, culture, and antibiotic
sensitivity testing.
• If gross pus is obtained from the aspiration ofthe digital
flxor sheath, surgical drainage usually is indicated.
• Vancomycin is effctive for gram-positive
• ciproflxacin is most effctive for gram-negative.
• If drainage is required, an open or closed irrigation
technique can be used.
• If the infection is chronic, or grossly necrotic
flex tendons, open drainage may be necessary.
• If an open technique is used, healing and rehabilitation
are prolonged and full motion may not be regained 40
• The goal is
– to adequately irrigate and drain synovial space
– place 5 French pediatric feeding tube in
proximal incision
– Irrigation should proceed from proximal to
distal to avoid proximal seeding
– Wound will left open to be wicked over 1 st 24
hrs
• If no clinical response within 24–48 hours
– extensive debridement should be pursued
• Active and aggressive hand therapy should begin 41
• expose the proximal end of the
flexor sheath in the region of the
A1
• make straight transverse incision
parallel to the distal palmar crease
■ Open the flexor sheath distal to
the A4 pulley.
■ pass a 16-gauge beneath the A1
pulley from proximal to distal in
the flexor sheath for 1.5 to 2 cm.
-Irrigate the sheath from proximal to distal
• Close the wounds around the catheter
• Suture the catheter to the palmar skin .

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 Deep space infections

• In 1905, Allen Kanavel, identified subfascial

or deep spaces as
subaponeurotic,
thenar
 midpalmar
 hypothenar
interdigital webspace,and Parona’s spaces

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• Deep space infections of hands are caused by
– direct penetrating trauma
– contiguous spread from other areas of hand
– rarely hematogenous spread
• S. aureus and Streptococcus species are most common
causative organisms
• Mainstay of management is
– Antibiotic therapy
– incision, irrigation and debridement
– wound should left open and packed with moist to dry
dressings
– hand should be splinted, elevated and closely monitor
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 Surgical approaches to deep spaces of hand

 subaponeurotic space
found on dorsum of hand bounded by extensor
tendons dorsally and metacarpals with interosseous
muscles volarly
present with edema and erythema on dorsum of hand
difficulty and pain with passive and active finger
extension
Approach through Longitudinal incisions

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 thenar space
located volar to fascia of adductor pollicis muscle
and dorsal or deep to index flexor tendons
Extend radially upto adductor pollicis insertion
and
midpalmar septum of third metacarpal ulnarly
• Presentation
thumb held in palmar abduction and is exquisitely
tender
In severe cases extends into first webspace and
dorsoradial aspect of hand
described as dumbbell or pantaloon infection
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• is characterized by a
widely abducted thumb
• fullness on the dorsum of
the first web space

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■ Drain the thenar space
through a curved incision in
the thumb web parallel to
the border of the first dorsal
interosseous muscle or
 along the medial side of
the thenar crease
 Avoid the recurrent branch
of the median nerve

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 midpalmar space: is located
deep to flexor tendons of long, ring and small
fingers and
superficial to long and ring finger metacarpals and
interosseous muscles
extends radially to septum of long finger
metacarpal and
Ulnarly to hypothenar musculature
• Presentation
volar hand edema with loss of palmar concavity
pain with passive motion of long and ring fingers
• Large incison exposure preferred
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 A midpalmar space
• abscess is characterized by
loss of the normal palmar
cocavity.
• The long and ring fingers
assume a partially flexed
posture
• there is pain on passive
extension of these fingers

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• Drained through a curved
incision
• beginning at the level of the
distal palmar crease,in z line
long fingure
• extending ulnarly to just
inside the hypothenar
eminence
• Other options include
- longitudinal distal palm
incision and the
- transverse palm incision.

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uptudate

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 Hypothenal space
 deep to hypothenar
musculature
 superficial to small finger
metacarpal
 bound radially by hypothenar
septum
 Infection of this space is
extremely rare
• Presents as swelling of
hypothenar eminence
• Use longitudinal incision over
hypothenar musculature
extending through hypothenar
fascia
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 References

• Neligan hand & upper Ext.4th edition

• uptudate 2021

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THANK YOU!!

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