OVERVIEWAetiology :- Who? manual workers & house- wives- 90 % Staphylococcus aureusPolymicrobial infections, Gram- negative organisms and anaerobic bacteria are documented- Mode of entry minor inj. & punctures
(.OVERVIEW(CONTC/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 function3- 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.
(PARONYCHIA (ACUTE Most common infection in the handLocalized superficial infection or abcess of the lateral nail foldTypically 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… Drain May need anesthesia (digital block) Soften by soaking If 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
(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 foldfor excision of the proximal one-third of the nail. (C-E) Incisions and procedure forelevating the entire eponychial fold with excision of the proximal one-third of thenail. 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. THEMAJORITY 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 THEPUS 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 THEINCISION WAS MADE WITH THE SCALPEL.
CHRONIC PARONYCHIA Chronic Paronychia of the Left Thumb Recurrent paronychiain the left index withinflammation of thenail folds. Recurrent orchronic paronychiamay be a sign of poorperipheral circulationor lowered generalresistance.
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 ((FELONDistal pulp space infection of theright thumb (arrow) ‘Felon’, anearly case, with three days ofincreasing 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) infectionof the distal finger typically resultsfrom direct inoculation of the virusinto broken skin. Infection by type 1 ortype 2 HSV is clinicallyindistinguishable. As in herpesinfections elsewhere in the body, it isbelieved that the virus can remaindormant in the neural ganglia, leadingto 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 pain Genital 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.
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 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 INFECTIONSThenar space infection. Fourdays after a puncture woundof the thenar crease there ispain, tenderness, swelling andrestricted movement. Themid-palmar space was alsoinvolved.
OPERATIVE METHODS(A) Volar transverse approachto the thenar space. Nerveinjury is a potentialcomplication. (B) Thenar creaseapproach. Nerve injury canresult from this approach. It hasthe added disadvantage oflimited drainage of the spacebehind the adductor pollicis. (C)Dorsal transverse approach. Acontracture of the web spacecan result if this incision isplaced too close to the edge ofthe web. (D) Dorsal longitudinalapproach to the thenar space.
MIDPALMAR SPACE INFECTIONSCollar stud abscessresulting from stabbingof the thenar creasewith an indelible pencil.The deep component ofthis abscess was in themidpalmar space whichbecame tender andswollen. The middlefinger is flexed becauseof involvement of itstendon sheath.
OPERATIVE METHODS(A) Transverse distalpalmar exposure of themidpalmar space. (B)Approach to themidpalmar spacethrough the lumbricalcanal. (C) Combinedlongitudinal andtransverse approach.(D) Longitudinalapproach to themidpalmar space.
HYPOTHENAR SPACE INFECTIONS Approach to thehypothenar space
WEB SPACE “COLLAR BUTTON” ABSCESSA dorsal thenar web space infection
OPERATIVE METHODS(A) Curved longitudinal volar incision for drainage of a web , (B) Dorsalincision used in conjunction with A. (C) Volar transverse incision, cancause web space contracture. (D) Volar exposure, used with dorsal incisionB.
DORSAL SPACE INFECTIONS Fig. : A deep dorsalFig. : Dorsal subcutaneous (subaponeurotic) spacespace infection following a bite infection in an elderly diabetic.over the metacarpo-phalangeal This abscess burstjoint of the ring finger. There is spontaneously and dischargedextensive dorsal swelling. foul smelling pus.
PYOGENIC FLEXOR TENOSYNOVITISFig. : Testing for local Fig. : Testing passive extension of the fingers. The hand rests on a table andtenderness over the gentle passive pressure is applied to theproximal end of the flexor fingernail. In a patient with septictendon sheath with a probe tenosynovitis such minimal movementor swab stick. of the flexor sheath produces exquisite pain.
OPERATIVE METHODSIncisions for drainage of tendonsheath infections. (A) Opendrainage incisions. (B) Singleincision for instillation therapyof tendon sheath infection. (C)Sheath irrigated via needleproximally and single distalincision. (D) Incisions forthrough-and-throughintermittent irrigation. (E)Closed tendon sheath irrigationtechnique. (F) Closed irrigationof 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
OSTEOMYELITISFig. : Acuteosteomyelitis. Five weeksafter penetration andinfection of the lateralpulp space, the thumbpulp remained painful,tender and slightlyswollen. Fig. : X-ray rarefaction of the distal phalanx.
PYOGENIC ARTHRITISSeptic arthritis occurringthree weeks after a bitewound to the dorsalaspect of the proximalinterphalangeal joint. Thefinger becameincreasingly painful untilpus discharged. Bitewounds are oftencomplicated by severeinfection.
COMPLICATIONS OF HAND INFECTIONS 1- Necrosis of Tendons 2- Skin Loss 3- Secondary Haemorhage 4- Persistent Oedema 5- Lymphangitis 6- Stiffness, Ankylosis and Contractures 7- Osteomyelitis and Septic Arthritis