3. Hand Infections
Introduction
In the pre-antibiotic era:
65% of hand disability resulted from minor injuries that became
infected
50 - 75% of all hand deformities were the result of infection
Kanavel’s study of the surgical anatomy of the hand:
defined anatomical planes and channels
careful placement of incisions for optimal drainage
became the cornerstone of treatment in the pre-antibiotic era
Penicillin changed the landscape:
severe hand infections are relatively uncommon today
incidence stable since 1940’s
4. Hand Infections
Antibiotics
valuable adjunct in infections but used alone will effect a cure
in only a limited number of situations
early diagnosis: 24 - 48 hrs.
high dose IV therapy
elevation & splinting to rest the affected part
Beyond this time success is unlikely:
thrombosis of small vessels
swelling & pressure within closed anatomical spaces
Abx need not be continued more than 7 - 10 days
exception: osteomyelitis
can usually switch to oral route in 2 - 3 days (if improving)
5. Hand Infections
Outline
Principles
High Risk Patients
Felons & Paronychia
Flexor Tenosynovitis
Deep Space Infections
Bites
IDU
Osteomyelitis
Septic Arthritis
Chronic Infections
6. Hand Infections
Introduction
Treatment principles
early & adequate decompression of pus to avoid soft
tissue loss
proper placement of incisions
avoids damage to adjacent structures
minimizes scar contracture
appropriate debridement of necrotic tissue
judicious splinting & early mobilization to minimize joint
stiffness
appropriate use of Abx as adjunct to prevent
dissemination of established infection
7. Hand Infections
Introduction
For infections requiring drainage, pre-operative planning is
required. Type & placement of incision should:
Allow direct access to
the abscess cavity
Permit easy extension
in any direction
Follow accepted principles
of hand surgery
8. Hand Infections
Introduction
Principles:
carry out procedure with optimal lighting, positioning,
visualization, analgesia & tourniquet control
Do not exsanguinate part as this may cause bacterial seeding
incisions don’t cross flexion creases at > 45°
avoid injury to vessels, nerves & tendons
avoid compromising the blood supply to adjacent area
avoid leaving a sensitive scar, especially in an important
tactile area
wounds left open are packed for 48 - 72 hrs. followed by
saline soaks & exercise
9. Hand Infections
High Risk Patient
Up to 50% of hand infections involve:
Diabetic / Immune compromised
IDU
Bites
Higher risk for developing severe complications:
Joint stiffness - Osteomyelitis
Contracture - Necrotizing Fasciitis
Amputation - Death
11. Felons
Anatomy of the fingertip
Distal phalanx is a closed sac separate from the remainder of
the digit
Closed pulp space divided into a latticework by multiple septa
Interstices filled with eccrine glands & fat
Dorsum is rigid (bound by DP & perionychium)
An increase in pressure of this compartment can adversely
affect the blood supply to the soft tissue & bone.
12. Felons
palmar closed-space infection of the distal pulp
severe pain, redness & swelling
Hx of minor penetrating trauma is usually present:
Minor cuts
Splinters
Glass slivers
most frequent causative agent: S. Aureus
untreated felons can:
extend toward the phalanx --> osteomyelitis
toward the skin --> draining sinus
obliterate vessels ---> skin slough or necrosis
supperative flexor tenosynovitis or septic arthritis of the DIPJ
13. Felons
Treatment
If recognized early (mild cellulitis): soaks & Abx
Later (abscess formation): surgical drainage
Usually process has been going on > 48 hrs.
Principles:
Avoid injury to n/v structures
Utilize an incision that won’t leave a disabling scar
Do not violate flexor sheath (stay distal)
Produce adequate drainage
14. Felons
Treatment
Multiple incisions described:
Fishmouth
J or hockey stick Poor choices:
- painful scar
Through & through - unstable tip
- anaesthetic tip
Volar transverse
Risks injury to digital
Midvolar longitudinal
nerve
Unilateral high midlateral
15. Felons
Treatment
Palmar incisions through the center of the pulp
Avoid crossing the DIP flexion crease (contracture)
Blade should only penetrate the dermis to avoid n/v structures and
then a clamp is used to spread the subcutaneous tissue
typically, drain over area of maximal tenderness or sinus
Disadv:: scar over tactile surface, risk injury to dig. nerve
16. Felons
Treatment
Unilateral longitudinal Incision
Best approach for most felons
Incise on lateral aspect of digit 5mm dorsal & distal to the DIP flexion
crease
Continue distally to a point 5mm away from the edge of the free nail
Deepen the incision with a clamp within a plane just volar to the
palmar cortex of the DP
Location of Incisions:
Index, middle & ring: ULNAR SIDE
Thumb & small: RADIAL SIDE
18. Paronychia
infection in and around the nail fold
Acute: any break in the seal between the nail and nail fold
may serve as a portal of entry for infection
hangnails
manicures
nail biting
usual causative agent: S. Aureus
in more advanced infections, pus may accumulate beneath the nail plate,
separating it from the underlying nail bed. This infection involves the
entire eponychium and is called an “eponychia”
Pus can also spread around the nail fold resulting in a “runaround
infection”
19. Paronychia
Treatment
If recognized early (mild cellulitis): soaks & Abx
Larger infections: drainage through the nail fold
Paronychial fold & portion of adjacent eponychium:
Remove 1/4 of nail
If this doesn’t allow drainage, incise fold away from matrix
20. Paronychia
Treatment
Eponychia:
Elevate eponychial fold and excise prox 1/3 of nail
Lateral (paronychial) incisions may aid in separating the nail base if
not already separated
21. Chronic Paronychia
Slightly different disease process with an indolent course
marked by exacerbations & remissions
Etiology: proximal nail fold obstruction + fungal infection
Often seen in people whose hands are constantly in a moist
environment
Inflammation of the eponychial fold, often with separation
from the underlying nail and intermittent drainage
usual causative agent: fungus > gram negative bacteria
Tx: eponychial marsupialization + topical antifungal
Crescent-shaped piece of skin excised proximal to nail fold
medical tx alone is largely unsuccessful
22. Tenosynovitis
Anatomy
Flexor sheaths are closed spaces
Extend from the mid-palmar crease
to the DIPJ
(Prox edge of A1 pulley to distal edge of A5 pulley)
Flexor sheath of small finger is
continuous proximally with the
Ulnar Bursa, while the sheath of
the thumb is continuous with the
Radial Bursa
Radial & Ulnar bursae extend
proximal to the TCL and connect
with the Parona space
(Potential space between FDP & PQ muscle)
23. Tenosynovitis
General
Flexor sheath infections most often as a result of penetrating
trauma
More likely at joint flexion creases
Sheaths are separated from skin by only a small amount of
subcutaneous tissue here
Also, Felons can rupture into the distal flexor sheath
Usual causative agent: S. Aureus
most commonly affected digits:
Ring, long & index fingers
24. Tenosynovitis
General
Purulence within the sheath destroys the gliding mechanism,
rapidly creating adhesions that lead to loss of function
destroys the blood supply producing tendon necrosis
25. Tenosynovitis
Clinical
Kanavel’s 4 cardinal signs:
Tenderness over & limited to the flexor sheath
Symmetrical enlargement of the digit (“fusiform”)
Severe pain on passive extension of the finger (> proximally)
Flexed posture of the involved digit
Not all four signs may be present early on
Most reliable sign: pain w. passive extension
Cellulitis of the hand may appear similar, but swelling &
tenderness is not usually isolated to a single digit
26. Tenosynovitis
Treatment
Early infection < 48 hrs (& usually lacking all 4 signs) may
initially be treated with IV Abx, splinting & elevation
Failure to respond within 24 hrs. should necessitate drainage
Established pyogenic tenosynovitis
is a surgical emergency
Requires prompt surgical drainage
Delays may result in tendon
&/or skin necrosis
27. Tenosynovitis
Treatment
2 basic approaches:
Open vs. Closed
Open drainage:
Decompression of the entire tendon
sheath via mid-axial & palmar incisions
Wounds are left open to drain & heal
secondarily
Rehab is prolonged; permanent finger
stiffness not infrequent
Most useful for advanced cases where
resection of necrotic tendon is required
28. Tenosynovitis
Treatment
Closed tendon-sheath irrigation:
2 incisions made
Proximal palm: open the sheath proximal to the A1 pulley
Distal mid-axial: open sheath distal to the A4 pulley
Long irrigation catheter (16 - 18g) is placed in the proximal sheath
with a drain left in the distal incision
Incisions are then closed, and sheath is irrigated for 48 - 72 hrs.
May use NS or Abx solution (continuous drip or q2h flush)
Addition of marcaine alleviates pain of irrigation
Modification involves multiple transverse incisions of cruciate pulleys
with insertion of silastic drains
29. Tenosynovitis
Treatment
These incisions:
ensure adequate drainage
heal quickly
Do not interfere with rehab
After removal of catheter and
drains begin gentle passive &
active ROM
30. Chronic Tenosynovitis
Unusual cases may be seen which present differently than
acute pyogenic infections:
Chronic swelling of the flexor sheath
No disabling pain or loss of function
These are chronic infections most frequently caused by
mycobacteria
usually the result of a puncture wound in an aquatic environment
M. Kansasii or M. Marinarum
Dx: AFB stains & culture of synovium
Tx: tenosynovectomy + antituberculous drugs (6 - 24 mo)
31. Deep Space Infections
4 deep spaces clinically significant in hand infections:
Subfascial palmar space
Dorsal subaponeurotic space
Thenar space
Midpalmar space
32. Deep Space Infections
Subfascial Palmar Space Infections
subfascial palmar space communicates with the dorsal
subcutaneous space via web spaces between the digits
usually spread dorsally (“collar button abscess”)
Double abscess: +/- palmar & dorsal abscesses connected through
hole in fascia
Palmar spread is limited by the relationship of fascia to skin
Causes:
Fissure in the skin between the fingers
Distal palmar callus (MC head)
Extension from subcutaneous infection in proximal finger
Severe distal palmar swelling with an abducted finger
Puss-filled web spaces
33. Subfascial Palmar Space Infections
Treatment
2 important points:
Do not incise web space transversely
Be alert for the double abscess configuration
Drainage is via a palmar approach with division of the palmar
fascia to expose both the volar & dorsal compartments
34. Deep Space Infections
Dorsal Subaponeurotic Space Infections
DSS is beneath the extensor tendons on the dorsum of the
hand
Often the result of penetrating trauma
IDU’s
neglected human bites
Dorsal swelling, erythema & tenderness + history make the
diagnosis
Drain via linear incisions over the 2nd & 4th MC’s while
preserving soft tissue coverage over the tendons
occasionally direct incision over a pointing abscess is necessary
Risks exposure (desiccation) of extensor tendons
35. Deep Space Infections
Thenar Space Infections
Thenar space follows the direction of Adductor Pollicis:
Dorsal: AP muscle
Volar: index flexor &
1st lumbrical
Radial: insertion of AP
(proximal phalanx of the thumb)
Ulnar: oblique septum from
skin to the 3rd MC
36. Thenar Space Infections
Clinical
Causes:
penetrating injury
thumb or index subcutaneous abscess
thumb or index flexor tenosynovitis
extension from radial bursa or
midpalmar space
marked swelling of the thenar
eminence & 1st web space
thumb forced into abduction
severe pain with extention or opposition
infection tracks dorsally via 1st web space,
over the AP & 1st dorsal interosseous muscles.
37. Thenar Space Infections
Treatment
Drain via volar or dorsal incisions
in the 1st web space or both:
Identify neurovascular structures
unroof the adductor fascia to open
the abscess cavity
irrigate & debride
catheter in volar incision & close;
penrose in dorsal incision & close
compressive dressing & plaster splint
38. Deep Space Infections
Midpalmar Space Infections
Boundaries:
Dorsal: intrinsic muscles
Volar: flexor tendons
Radial: oblique septum from
the skin to the 3rd MC
Ulnar: hypothenar muscles
Distal: vertical septa of palmar fascia
Prox: fascial layer at distal carpal tunnel
39. Deep Space Infections
Midpalmar Space Infections
Clinical:
usually due to direct penetrating trauma, rupture of tenosynovitis
loss of palmar concavity, dorsal swelling, tenderness volarly
40. Midpalmar Space Infections
Treatment
Drain via wide palmar incisions
with +/- resection of palmar fascia
to ensure drainage of abscess cavity.
or may place irrigation catheter &
drain and close primarily.
41. Bursal Infections
Usually due to spread of flexor tenosynovitis from thumb or
small finger
Radial bursa:
Proximal extension of
tendon sheath of FPL
extends through the carpal
tunnel into the distal forearm
Ulnar bursa:
Proximal extension of tendon
sheath of FDP of small finger
42. Bursal Infections
Treatment
Closed irrigation using 2 incisions, a catheter & a drain as
previously outlined.
43. Human Bites
Often undertreated & misdiagnosed leading to significant
morbidity
The most serious form of human bite infection is the clenched
fist injury:
Any laceration over the head of a metacarpal
is a human bite injury until proven
otherwise
44. Human Bites
The wound that results from a punch to the mouth may
appear insignificant and treatment may not be sought for
days.
It often results in immediate inoculation of the subcutaneous
tissue, the subtendinous space and the MCP joint with saliva
Human saliva may contain over 108 microorganisms per ml.
Over 42 species of bacteria identified
Thus: Polymicrobial infection is the rule
Common organisms:
S. Aureus, Strep sp.,
Eikenella: gram neg facultative anaerobe in ~ 30% (incr. severity)
45. Human Bites
Delay in onset of treatment is directly proportional to poor
outcomes:
In general, human bites treated within 24 hrs. rarely have serious
complications
in E.D.:
Debride, irrigate, pack open
Abx to cover gram +’s & eikenella (Pen & Ceph)
+/- admission to follow response
To O.R.:
Established joint space penetration, & more severe infections
46. Animal Bites
Dog more common than cat (5%)
Cat bites are particularly virulent & can result in deep puncture
wounds that are hard to clean
More than half involve kids
Basic principles of debridement & irrigation apply
Deep puncture wounds are left open & may require extension
Established infections are debrided & packed open
Superficial lacerations may be loosely closed after irrigation
Common organisms:
S. Aureus, Strep viridans, Pasturella (#1 in cats), anaerobes
Abx: ampicillin (Clavulin on outpatient basis)
47. Injection Drug Use
Common sites of infection:
Dorsum of hand
Radiodorsal area of the wrist
Palmar aspect of the forearm
Dorsum of the fingers at the PIPJ
Clinical spectrum:
Cellulitis
Subcutaneous abscess
Flexor tenosynovitis
Septic joints
Osteomyelitis
Necrotizing fasciitis
48. Injection Drug Use
Source of infection from a variety of sources
Skin
Saliva
Bowel
Tx:
Admission
elevation of limb
broad spectrum IV Abx
analgesia (may need support from APS or CDRT)
+/- debridement & irrigation
Medicine consult
49. Hand Infections
Osteomyelitis
Almost always the result of adjacent spread
wound infection
joint infection
tenosynovial infection
Also, direct penetration
(hematogenous spread is rare)
most commonly S. Aureus
Bone necrosis: hallmark
microorganisms reside in dead bone
If caught early, before extensive bone necrosis occurs, it may
be cured with Abx alone.
50. Osteomyelitis
Diagnosis
Xrays:
Early radiographs may be normal
It takes at least 10 days for matrix
to mineralize & areas of increased
density to be detected.
Lytic lesions; sclerosis (1 month)
Bone Scan:
Can pick up osteomyelitis early, but less specific
Prompt surgical exploration is the most reliable way to
establish the diagnosis
51. Osteomyelitis
Treatment
Approach depends on location of involved bone:
Phalanx: mid-axial incision
Metacarpals: dorsal approach
all infected bone must be removed
Soft bone may be curetted
may need to use drill holes to remove a small window of cortical bone
for decompression of the infection
routine post-Op care or may also use constant irrigation
methods (1 wk)
severe, extensive involvement of a digit may be best treated
by amputation
Will prevent stiffness & major disability of the uninfected parts
52. Hand Infections
Septic Arthritis
usually the result of penetrating trauma:
bite or tooth wound
also, spread from soft tissue or bony infection
joint is swollen, warm & tender
pain with axial loading
passive motion is restricted & painful
Xrays:
thinning of joint (cartilagenous loss)
resorption of subchondral bone
osteomyelitis (late)
aspiration of joint for C & S
53. Septic Arthritis
Treatment
Drainage is imperative as soon as the diagnosis is made
Destruction of the articular cartilage by lysozymal activity
approach is through a longitudinal dorsolateral incision over
the affected joint
access to the joint is via an incision dorsal to the cord portion
of the collateral ligament
joint is irrigated & debrided
packed open for 48 - 72 hrs. (or closed over irrigation)
packing removed and gentle ROM begun
wound granulates closed
54. Hand Infections
Chronic Infections
Atypical mycobacterium infections:
penetrating wound often in a marine environment
prolonged, relatively non-painful swelling of finger, palm or wrist
Tuberculous & atypical mycobacteria have a predilection for synovial
tissue of joints & tendon sheaths
Tenosynovium is thick, infected & hypertrophic. It surrounds the
tendons & erodes the pulleys.
Dx: culture synovial biopsy
Noncaseating granulomas & AFB
Tx: thorough joint synovectomy
For ++ joint damage: rest the joint until the infection is cured before
undertaking reconstruction
For tenosynovium: complete synovectomy sparing the pulleys
Start anti-TB meds empirically (around time of synovectomy)
55. Hand Infections
Chronic Infections
Tuberculous Infections:
less common now than several decades ago
Presents in a similar manner as atypical mycobacterial
infections
Tx: as above, synovectomy + anti-TB drugs
In addition, can produce a dactylitis
Enlarged fingers
Proliferation of subperiosteal reaction on Xray
Tx: surgical excision & curettage of the involved areas
56. Hand Infections
Chronic Infections
Leprosy:
M. lepraemurium
Predilection for cooler areas of the body including the hands
Most frequently produces a neuropathy involving the ulnar nerve:
intrinsic atrophy
clawing
weakness in pinch
Tx: surgical procedures limited to reconstruction for the neurological
deficits
57. Hand Infections
Chronic Infections
Fungal Infections:
except for biopsy for diagnostic purposes, surgical treatment is rarely
necessary
best treated with systemic &/or local anti-fungal agents
occasionally a tenosynovitis, septic arthritis or osteomyelitis is seen:
Appropriate debridement required as above
Mainstay is still anti-fungal agent
58. Post Op Care
Wound care & early initiation of therapy are key in achieving
good functional results in treating hand infections
In general:
wounds are debrided, irrigated & packed open
packing usually removed 24 - 48 hrs. post-op
initiation of regular wound cleansing
gentle active ROM
splints may be helpful in enhancing joint motions
early involvement of a hand therapist is important in achieving a good
functional result.