approx 35% of patients admitted to hand surgery services. Majority are result of minor trauma for which treatment is delayed or neglected. Occasionally these are results of drainage efforts by patients themselves under aseptic conditions.
Uncomplicated Infections: Antiobitics alone will suffice. Evolved infections with localized collections: Antiboitics Drainage.
Any surgeon who accepts the responsibility fordrainage of a hand infection must undertakecomprehensive management responsibilities including: Preoperative Planning Surgical Approach Postoperative Care Rehabilitation.
A. EvaulationB. Operative PrinciplesC. Rest/Heat/ElevationD. Inpatient Care
A: EVALUATION HISTORY: o Reveals the source of infection or predisposing factors. o Previous injury to the site o Bites --- Splinter --- Needle sticks --- surgical procedure o Hand Dominance & Occupation o exposure to certain pathogens. o History of Systemic diseases like DM, immunocompromised states.
SYMPTOMS: o Timing of events o Pain o Loss of function o Drainage o Fever o Chills.
Physical Examination: o Exposure of whole extremity o Signs of lymphangitis and lymphadenopathy o A systemic approach to avoid missing critical information.
RADIOGRAPHS: o Retained foreign bodies o Rule out osteomyelitis o Gas gangrene o Serve as baseline for future comparison.
A. EvaulationB. OPERATIVE PRINCIPLESC. Rest/Heat/ElevationD. Inpatient Care
B: OPERATIVE PRINCIPLES 1. Incisions should never cross a flexion crease at a right angle2. Avoid iatrogenic injury to critical structures 1. Tendons 2. Neurovascular bundles3. Incision lengthening is usually needed and should be planned by making potential extensions with a pen.
4. Torniquet Control is helpful as infective processcan lead to profuse bleeding. o Finger Torniquet o Penrose drain o Glove technique o Standard Pnematic Torniquet with exanguination o Esmarch bandage o Elevation of limb with digital pressure on brachial artery.
A. EvaulationB. Operative PrinciplesC. REST/HEAT/ELEVATIOND. Inpatient Care
C: REST – HEAT - ELEVATION a. REST (IMMOBILIZATION) o Limits opening of tissue plans restricting the spread of infection. o Should be done in a functional position.
b. HEAT (WARM MOIST SOAKS): o Maximum vasodilatory effect reached in 10 min. o Frequent soaks preffered over continous soaks. o Severe Infections: o Moist hot towels with plastic barrier and a dry towel as insulator.
c. ELEVATION: o Reduces edema by improving venous/lymphatic drainage. o Limb should be above level of heart for dependant drainage. o Limb placed over chest or on a pillow while sitting.
A. EvaulationB. Operative PrinciplesC. Rest/Heat/ElevationD. INPATIENT CARE
D: INPATIENT CARE IV antiboitcs is the most common justification for hospitalization. Continuous or intermittent wound irrigation. Frequent dressing changes. Three phases of treatment in cases of severe infections where extensive debridement and complex reconstructions are needed.
Phase 1> Rapid infection contrtol and staged debridement. A second look surgery done in 24-48 hours. Phase 2> Salvage of vital structures and soft tissue coverage. With identification of structures that will later require reconstruction. Phase 3 > Reconstructive Surgery. Once stable soft tissue coverage is achieved.
ANTIMICROBIAL THERAPY Antiboitcs are indespensible adjuncts. Cultures should be obtained prior to antiboitics use. Most common pathogens involved are Staph aures and Streptococcus sp. Usually gram +ve coverage is first choice. Consider MRSA while treating infections depending upon patterns of resistance in a particular area.
Cause: Inocculation of bacteria as a consequence of minor trauma such as Nail bitiing Poor manicuring Small puncutre wounds. Staph aureus is most common pathogen but anaerobes may also be involved.
UNCOMPLICATED INFECTION: Oral antiboitics / Rest / Heat / Elevation INFECTION WITH ABCESS: Localized to one nail fold; Elevation of fold bluntly with a haemostat Using no 11 blade directing away from nail bed through the insensate epithelium where abcess is pointing.
Eponychia (involving proximal nail & one lateral fold; Elevating the eponychial fold and removal of loose portion of nail plate to drain abscess and allow for secondary healing.
Pulp Anatomy: 15-20 longitudonal septa anchoring skin to distal phalanx dividing the pulp into multiple closed compartments.
Pathophysiology: Abscess formation within these small compartments results in rapid development of swelling and throbbing pain, worsened by dependency. Complications: Necrosis of entire pulp Extension of infection into; Flexor tendon sheath Distal IP joint Distal phalanx.
Causes: Mostly Puncture wound with foreign body, so radiographs are mandatory. Pathogen: Staph aureus but gram –ve infection can also occur esp in immunocompromised patients. Conservative Management: For early Felons… Oral antiboitics Rest Warm Soaks Elevation.
Basic principles of Incision drainage; Avoid iatrogenci injury to neurovascualar structure Leave an acceptable scar Avoid flexor tendon sheath Drain all fluid collections adequately. Two types of INCSIONS: Volar Longitudonal incision Hockey stick or J- inscion
D: HERPETIC WHITLOW Herpex simplex virus infection can be: Primary Recurrent Population at risk: Children, adolesents with genital herpes infection Health care workers with frequent exposure to oral secretions. Must be distinguished from Paronychia and Felon because incision and drainage is generally contraindiacted.
Pathophysiology: A prodromal phase of 24-72 hours of burning pain prior to the development of skin changes. Erythema and swelling Formation of clear vesicles which sometimes coalsease around nail fold. Fluid may become turbid but not frankly purulent unless bacterial superinfection occurs. Pulp of affected digit is not tense as in felon.
Disease Course: The process occurs over approx 2 weeks and resolves over next 7-10 days. Diagnosis: Viral culture Tzanck smear Treatment: Generally conservative Rest & Elevation Anti inflammatory agents Acyclovir in immunocompromised states. Reccurence rates are around 20%.
E: PALMER SPACE INFECTIONS Thenar space Midpalmer space (subtendinous space) Hypothenar space Dorsal subapeneurotic space Web spaces. Thenar and midpalmer spaces are clinically more important.
THENAR SPACE INFECTIONMIDPALMER SPACEINFECTION
A penetrating injury usually a splinter is the most common cause. Staph aureus is the usual pathogen. Antiboitics / Rest / Heat / Elevation for early infections but most cases need Surgical Drainage. Key to success is adequate drainage while avoiding iatrogenic injury and subsequent scar contracutres.
Midpalmer space infectionincisions and proceedures: Curved longitudonal incision in the palm. Take care to avoid injury to superficial palmer arch and digital vessels. Wound packed open with daily dressing changes. OR Irrigation catheter in proximal wound and a penrose drain in distal wound for continous or intermittent irrigation.
Thenar space infection incision and procedure: Combined dorsal and volar incisions. Take care to avoid injury to palmer cutaneous branch of median nerve in proximal end of incision And avoiding injury to motor branch of median nerve. Post op care include Splinting Dressing changes Catheter irrigation.
F: PYOGENIC (SUPPARATIVE) FLEXOR TENOSYNOVITIS: Most serious hand infection. If left untreated; Destruction of gliding surfaces in sheath Necrosis of tendons Osteomyelitis Amputation. Ring, middle and index fingers mostly involved Staph aureus usual pathogen with few cases due to haematogeneous spread of gonococcal infection.
KANAVEL cardinal sign of flexortenosynovitis:1. Fusiform swelling of finger2. Paritally flexed posture of digit3. Tenderness over entire flexor sheath4. Dipropotionate pain on passive extension.
< 48 hours of onset of infection: IV antiboitics Rest / Heat / Elevation > 48 hours of onset of infection: Surgical drainage with zig zag brunner incisions Wound is packed open and loosely approximated Early and aggressive hand therapy initiated. Less severe cases: Catheter irrigation with limited incision .
a. Human bites: Potenitally serious due to high virulence of pathogens invovlved. Common mechanism is clenched fist striking a tooth, FIGHT BITE. Usually delayed presentation. Most commonly over the MCP joint, putting the extensor mechanism and joint surface at risk. Radiographs are mandatory and may reveal; Tooth fragment Fracture of Metacarpel head Air in joint.
All human bites in MCP joint region should be explored; Joint space irrigated Edges debrided Primary wound closure never done. Closed after a week or 10 days in severe cases Antiboitics / Rest / Heat / Elevation Usually covering gram +ve and anaerobes.
b. Animal bites: Domestic Dogs and CatsTetnus status should be ensured.Rabies prophylaxisThorough irrigation and exploaration of joints when potentially voilated.
CAT bites can present late with closed space abscesses due to trapping of bacteria inside wounds
CAT scratch FEVER; Small pustule with surrounding edema at site of cat bite Painful lymphadenopathy Symptomatic treatment Anti inflammatory Antiboitics Pain resovlves in 2 weeks but lymphadenopathy can persist for months or years.
H: SEPTIC ARTHRITIS Destruction of articular surfaces. Mode of infection: Penetrating injury Local extension of adjacent infection Haematogenous spread (Gonococcal infection) Children; Streptococcus sp Staph aureus H. Infulenza Adults; with no history of trauma Suspect Gonococcus.
Presentation; Septic joint will be Swollen Tender warm Marked pain on passive motion. Patient position of hand is to allow maximum joint space; IP joints in 30 degree flexion MCP full extension
Exploration is mandatory and joints are copiously irragated and debrided. Joint packed open and dressing changes performed. Wound left to close by secondary intention. Antiboitics Rest / Heat / Elevation.
I: NECTROTIZING FASCITIS A life threatening, rapidly progressing infection of the subcutaneous tissue and fascia. Diabetics and immunocompromised patients are at greater risk.
Pathogenesis; Low grade cellulitis bullous changes in skin cutaneous anesthesia with spread into underlying subcutaneous tissuefat necrosisvascular thrombosiMyonecrosiscutaneous vessel thrombosis.
Mixed infection; Aerobes Anaerobes Clostridium sp result in gas formation in tissues with crepitus on physical exam and air in tissues on radiographs. Treatment: Repeated aggressive radical debridements Amputations above area of involvement Silvadene cream IV High dose antiboitics and tissue culture Hyperbaric O2.
A: CHORNIC PARONYCHIA Presentation: Eponychium is; Indurated Erythamatous Occasional drainage from nail fold. Population at risk; Diabetics Frequent occupational exposure to moist conditions CANDIDA ALBICANS is the most common pathogen.
Medical Management: Topical antifungal Topical steroids Removal of thickened, deformed nail plate. Surgical Management: Eponychial Marsupalization.
B: OSTEOMYELITIS Mode of infection: Direct extension from an adjacent infection Septic arthritis Flexor tenosynovitis After open fracture Haematogenous seeding. Causative Bacteria: Staph aureus Hemophilus sp in young children.
Presentation: Chronically draining wound Erythema Pain Swelling along the course of bone. Diagnosis: Radiographs Bone scans CT / MRI Bone culture and bone biopsy (Gold standard) Swab cultures
Treatment: Long term antiboitic use for 4-6 weeks even upto 6 months. Spectrum kept broad at first, then narrowed based on bone culture sensitivities. Bone curettage during biopsy taking. 40% cases still need amputation.
C: ONCHOMYCOSIS (TENIA UNGUIUM) Infected nails appear thickened and discolored Nail eventually separates from nail bed. Nail appear flaky. Causes: Trichophyton rubrum most common Candida albicans usually in diabetics. Fungal cultures always obtained prior to antifungal therapy.
Trichophyton rubrum responds best to oral Terbinafine. Candida can be treated with; Topical nystatin Miconazole Oral ketoconazole Itraconazole Griseofulvin. Removal of nail plate may imporve response for extensively involved nails.