Acute hand infections in hand surgery

1. Aliyas Yeldo

2. CONTENTS
• ACUTE PARONYCHIA
• CHRONIC PARONYCHIA
• FELON
• PYOGENIC FLEXOR TENOSYNOVITIS
• RADIAL AND ULNAR BURSAL AND PARONA
SPACE INFECTIONS
• DEEP SPACE INFECTIONS

3. ACUTE PARONYCHIA

4. • Nail complex consists of the nail bed, nail plate, and perionychium.
• The nail bed consists of -the germinal and sterile matrices.
• Germinal matrix- responsible for the majority of nail growth.
• Proximal portion of the nail sits below the nail fold.

5. • Perionychium- border tissue surrounding the nail .
• Eponychium-thickened layer of skin at the base of the fingernails
• Hyponychium- Mass of keratin just distal to the sterile matrix, below the distal nail
plate- highly resistant to infection.

6. • Most common infection of the hand
• Acute paronychia involves the soft tissue fold around the fingernail
Pathophysiology
• Results from the bacterial inoculation of the paronychia tissue
• By a sliver of nail or hangnail
• a manicure instrument, or
• through nail biting or
• constant exposure to wet surroundings
Disruption of the barrier between the nail fold and the nail plate allows the
introduction of bacteria into the tissue bordering the nail
Most paronychias are mixed infections, the most common infecting organism
is S. aureus.

7.  Eponychia- Infection involving the entire eponychium, as well as
one lateral fold
 Presents as -Collection of pus beneath the proximal portion of the
nail in the region of the lunula
• Runaround infection- Because of the continuity of the nail fold
with the eponychial tissue overlying the base of the nail, the
infection can extend into this region and may continue around to
the fold on the opposite side of the fingernail. This is very rare

8. CLINICAL PRESENTATION

9. TREATMENT
EARLY MANAGEMENT
• Soak in warm solution
• Oral antibiotics
• Rest for the affected parts
• Superficial abscess- requires drainage under LA
• Cuticle elevated away from the nail plate in the area of
erythema
• the thin layer of tissue over the abscess is opened with a
sharp blade directed away from the nail bed and matrix.

10. • The patient is counseled regarding high-risk
activities, such as nail biting and manicures.
• Subungual abscesses are treated with removal of
portion of or the entire nail. Abscess is carefully
debrided while protecting sterile or germinal
matrices

11. • EPONYCHIUM
• When abscess or fluctuance is found below
the eponychium a parallel incision along the
opposite nail fold is made, allowing the
eponychium and nail fold to be elevated and
reflected above the nail plate to drain the
abscess

12. CHRONIC PARONYCHIA
CLINICAL PRESENTATION
Characterized by chronically indurated and rounded eponychium
 Thickening and grooving of the nail plate.
PATHOPHYSIOLOGY
• Begins with Separation between the nail plate and the dorsal soft tissue covering
the nail plate- leads to colonization by staph species –
• Subsequent infection by candida Or colonic organisms leads to chronic
inflammation and recurrent exacerbations with episodic increased erythema and
drainage.
• This Chronic inflammation causes Fibrosis and thickening of the eponychium-
decrease in vascularity to the dorsal nail fold-reduces the resistance to minor
bacterial infections- reccurent exaceberations

13. RISK FACTORS
 Frequent water immersion, particularly in detergents
and alkali solutions
 Housewives, dishwashers, Swimmers, and children who
suck their fingers are often affected.
 Also more commonly affects patients with Diabetes and
psoriasis
ORGANISMS
gram-positive cocci
gram-negative rods,
Candida, and
Mycobacterial species

14. TREATMENT
CONSERVATIVE
• Topical corticosteroids, oral and topical antibiotics, and oral and topical
antifungal agents + avoidance of exaceberating factors
• Less success
SURGICAL
• Marsupialisation under LA

15. • EPONYCHIAL MARSUPIALIZATION
• Crescent-shaped incision of the eponychial nail fold
• The crescent should be symmetrically shaped and extended to
the edge of the nail fold on each side
• The crescent of tissue is removed down but not including the
germinal matrix. The wound is left open and allowed to drain
• Remove nail if deformity present

16. FELON
• Felon- latin for bile or venom
• A felon is a subcutaneous abscess of the distal pulp of a finger
or thumb involving multiple septal compartments and causing
compartment syndrome of the distal phalangeal pulp
• MC organism- S. aureus.

17. PATHOPHYSIOLOGY
• Direct innoculation with penetrating trauma
• “Finger-stick felons”-seen in diabetics, who repeatedly traumatize
the fingertip for blood tests
• Expanding abscess breaks down the septa and can extend toward
the phalanx and produce osteitis or osteomyelitis, or extend
toward the skin and cause necrosis and a sinus somewhere on the
palmar surface of the digital pulp.
• Patient usually tries to decompress the abscess
• Infection- edema –increased pressure within closed compartment-
impaired venous outflow and local compartment syndrome

18. CLINICAL PRESENTATION
• MC : Thumb and index finger
• Severe throbbing pain,
• Tension and Swelling localised to pulp

19. TREATMENT
• Conservative management has little role
• By the time of presentation- the pulp is tensely swollen and
tender
• SURGICAL DECOMPRESSION is Treatment of choice
• Principles
To preserve function of pulp-fine tactile sensibility and
a stable durable pad for pinch.
Avoid injury to nerves and vessels
No disabling scar
Adequate drainage
Not to violate flexor sheath

20. Longitudinal incision is preferred at point of maximal tenderness
It avoids –skin slough, digital nerve injury , creation of unstable fat pad
Longitudinal volar incision
Abscess located at middle of the pulp or sinus is present
Unilateral longitudinal incision
Point of tenderness located at side of the pulp

21.  To avoid penetration of the tendon sheath,
the incision should not extend to distal IP
crease
 Incise dorsal to and 0.5 cm distal to the DIP
joint flexion crease.
 Continue distally in line with the volar margin
of the distal phalanx 5mm away from edge of
free nail
 Deepen along a plane just volar to palmar
cortex of Distal phalanx
 All involved septa is opened
 Culture is taken.
 Distal phalanx examined with a probe and
rough or softened surface indicates bone
involvement-which requires débridement

22.  Location of incision
• IF MF RF – ulnar side
• Thumb and LF radial side
Initial empirical antibiotic coverage with 2nd gen cephalosporins
and based on sensitivity
 Gram negative coverage in immunocompromised individuals
Post operative wound care
Elevation of limb
mobilisation under therapy supervision

23. PYOGENIC FLEXOR TENOSYNOVITIS
Pyogenic flexor tenosynovitis is a closed-space infection of the flexor
tendon sheath of the fingers or thumb
ANATOMY
 Double-walled structure with visceral layer and parietal layer.
– Visceral layer – closely adherent to the tendon (epitenon).
– Parietal layer- lies adjacent to the pulley system.
– These two layers are connected proximally and distally,
creating a closed system.
 Extends from mid palmar crease to the DIP level (Proximal edge
of A1 pulley to distal edge of A5 pulley)
• In the fingers, the sheaths begin in the palm at the level of the
metacarpal neck and end distally just proximal to the DIP joint
• small finger- there is usually continuity between the flexor
sheath and the ulnar bursa, which extends to a point just
proximal to the transverse carpal ligament.

24.  Thumb, a similar connection is seen with the radial
bursa, which also extends proximal to the transverse
carpal ligament.
 Proximally, the radial and ulnar bursae have a potential
space of communication through the Parona space,
which lies between the fascia of the pronator quadratus
muscle and flexor digitorum profundus (FDP) conjoined
tendon sheath.
 This connection between the thumb and small fingers
through the radial and ulnar bursae gives rise to the
horseshoe abscess, in which a flexor sheath infection of
the thumb or small finger tracks proximally to the wrist
and then ascends along the flexor sheath on the
opposite side.

25. CLINICAL PRESENTATION
• Penetrating trauma – MC cause of infection- typically over the volar aspect of PIP or
DIP joint
• Heamatoganous spread-Rare –Disseminated Gonococcal infection
• MC organism – Staph Aureus
• MC affected – RF MF IF
• Gliding mechanism if tendons are affected by the suppuration
• The flexor tendons receive their nutrient support from a direct vascular supply and
diffusion from the synovial fluid. Purulence can also destroy the blood supply,
producing tendon necrosis

26. • Kanavel’s four cardinal signs
1. A semi flexed position of the finger
2. Symmetric enlargement of the whole
digit (fusiform swelling)
3. Excessive tenderness limited to the
course of the flexor tendon sheath
4. Excruciating pain on passively
extending the finger along the flexor
sheath-not localized to joint or abscess.
• Most reliable sign – pain on passive
extension
• Cellulitis of hand present with similar
complaints but swelling and tenderness
not usually isolated to single digit

27. TREATMENT
CONSERVATIVE
• Little role
• Present within the first 24 hours of the onset of symptoms,
have mild pain and mild swelling or 1 or 2 Kanavel signs
• Admit – IV antibiotics
• Elevation and splinting
• Observe- 12 hours – no improvement - surgery
• Contraindicated in diabetic or immunocompromised
• Culture from aspiration send before ABX

28. OPERATIVE
OPEN APPROACH
• Midlateral inscision
• The incision is made dorsal to cleland’s ligament
• It extends from the middle of the distal phalanx to just
proximal to the web space.
• Tendon sheath opened distal to the a4 pulley.
• A 1.5- to 2.0-cm transverse volar incision made proximal
to the a1 pulley to expose the proximal flexor sheath
• Decompression of entire tendon sheath
• Wounds left open to drain and heal secondarily
• This allows Direct access to the tendon sheath
• Can lead to greater scarring and stiffness of the finger
• IF MF RF – ulnar border
• Thumb and LF – radial border.

29. CLOSED IRRIGATION METHODS
• 2 inscisions
• Proximal palm – to open the sheath proximal
to A1 pulley
• Distal mid axial- To open Sheath distal to A4
pulley
• 16-18g long irrigation catheter placed in proximal
sheath with a drain left in the distal incision
• The catheter is sutured to the skin, and the wound
closed around it. Sheath-irrigated with saline or ABX
solution
• Hand is dressed and splinted, with the catheter brought
out of the dressing and connected to a continuous drip
50ml q2h for 48 hours

30. RADIAL AND ULNAR BURSAL AND
PARONA
SPACE INFECTIONS
• Occur rarely in isolation- commonly
associated with flexor tendon sheath
infections of the small finger or thumb.
• Radial Bursa-continuation of the tendon
sheath of the flexor pollicis longus (FPL)
tendon
• Ulnar Bursa-begins at the proximal end of
the small finger flexor tendon sheath and
widens more proximally, overlapping the
mid 4th metacarpal and the proximal base
of the 3rd and 4th metacarpals.

31. • Communications
– Small finger flexor tendon sheath with the ulnar
bursa-50%
– Radial and ulnar bursa communication-85%
• Space of parona- Deep potential space in the
distal volar forearm.
– lies Between the fascia of the pronator quadratus
and sheath of the FDP tendons.
– It is in continuity with the Midpalmar space
– Not in direct continuity with radial and ulnar
bursa- rupture leads to infection

32. CLINICAL FEATURES
• Similar to those of pyogenic flexor tenosynovitis of the thumb
and small finger
• Cardinal signs of kanavel
• Tenderness over thenar and hypothenar space
• According to Kanavel –
• Ulnar bursal infection-presence of tenderness at the junction
of the distal flexion crease of the wrist and the hypothenar
eminence.
• Radial bursal infection- There is tenderness at the junction of
the distal wrist flexion crease and the thenar eminence
• Isolated infections of Parona space- rare- present as swelling,
tenderness, and, fluctuance in distal volar forearm.
• Median Nerve involvement-Symptoms of numbness and tingling
due to swelling or fluid present in the midpalmar space

33. TREATMENT
• No role of non surgical treatment
• Boyes inscision
Ulnar Bursa
– 1st incision -parallel to the proximal edge of the A1 pulley and It can be extended proximally
along the radial margin of the hypothenar crease
– 2nd incision - 3-inch incision, beginning just proximal to the wrist flexion crease for proximal
part of the bursa. It is parallel to the volar edge of distal ulna
Radial bursa- through a distal incision placed at the level of the thumb MP joint.
Parona space- Same as proximal inscsion of ulnar bursa
• Bursa is exposed, opened, and drained.
• Cultures are taken.
• Proximal-to-distal irrigation with a 14- or 16-gauge angiocath
• Closed with drain

34. DEEP SPACE INFECTION
Three anatomically defined potential spaces.
These septated spaces lie between muscle fascial
planes
 Thenar
 Midpalmar,
 Hypothenar
Three superficial spaces in the hand,
 The dorsal subcutaneous space,
 Dorsal subaponeurotic space,
 Interdigital web space.

35. THENAR SPACE
• Most common of deep space infections
• Often track dorsally into space between first dorsal interosseous muscle and
adductor pollicis muscle
• Confused with dorsal subcutaneous abscess if there is dorsal extension of
abscess cavity
• Boundaries
– Dorsal: Adductor pollicis, second metacarpal
– Volar: Flexor Tendon sheath of index finger and radial palmar fascia
– Radial: Insertion of adductor pollicis (Prox PLX of thumb)
– Ulnar: Midpalmar oblique septum from skin to 3rd MC

36. Causes
• Penetrating trauma.
• Thumb or index subcut abscess
• Thumb or index flexor tenosynovitis
• Extension from midpalmar space or radial bursa
Clinical features
• Swelling and tenderness of thenar eminence
• Thumb is abducted
• Pain with passive adduction
• Infection tracks dorsally via 1st web space over AP
and 1 st dorsal interossei

37. TREATMENT
• No role for nonsurgical management of deep
space infections.
• Surgical emergencies
• IV antibiotics are started- changed based on cs.
• Drain via Volar or Dorsal or combined incision in
1st web space
• Neurovascular structures identified
• Recurrent branch of median nerve at risk in
volar incision
• Unroof adductor fascia and open abscess cavity
• Irrigate and debride
• Catheter in volar inscsion and close
• Penrose drain in dorsal inscision and close
• Compressive dressing done

38. MIDPALMAR SPACE
• Rare infection
• Boundaries
– Dorsal:Fascia overlying second
and third volar interosseous
muscles and third, fourth, and
fifth metacarpals
– Volar: Flexor sheaths of
middle, ring, and small fingers
and palmar aponeurosis
– Radial: Midpalmar oblique
septum
– Ulnar: Hypothenar septum
– Distal: Deep transverse fascia
at level of MC head
– Proximal: Base of palm

39. CLINICAL FEATURES
 Dorsal swelling predominates
 Loss of palmar concavity (becomes convex)
 flexed posture of fingers (long and ring)
 Pain with passive extension of fingers-less than with septic
flexor tenosynovitis
CAUSES
• Penetrating trauma
• Rupture of tenosynovitis

40. Treatment
• Incisions
(1) Transverse incision in the
distal crease
(2)Combined transverse and
longitudinal approach
(3) Curved longitudinal
approach
• The common digital nerves
and arteries as well as
superficial palmar arch-
protected.
• Flexor tendons of the RF-
used as a guide

41. • Deep dissection is continued longitudinally on
either side of tendons till abscess is opened
• Irrigation catheter or drain placed and closed
primarily after debdridement

42. HYPOTHENAR SPACE
• Extremely rare;
• Distinctly separate anatomic space-not in continuity with -flexor tendon sheaths
• Boundaries
 Dorsal: 5th carpal And deep hypothenar Muscles
 Volar: Palmar fascia and fascia of Superficial hypothenar muscles
 Radial: Hypothenar septum
 Ulnar: Fascia of hypothenar muscles

43. CLINICAL FEATURES
• Localized tenderness and swelling of hypothenar eminence;
• no palmar swelling;
• no finger or flexor tendon sheath involvement

44. TREATMENT
• Incision in line with ulnar border of
RF, Proximal to the midpalmar
crease to 3cm distal to wrist flexion
crease
• Purulance evacuated
• A gauze dressing and/or Penrose
drain is placed in the wound.