Hand infections

9,460 views

Published on

Published in: Health & Medicine

Hand infections

  1. 1. Dr. Tauseef ul Hassan
  2. 2.  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.
  3. 3.  Uncomplicated Infections:  Antiobitics alone will suffice. Evolved infections with localized collections:  Antiboitics  Drainage.
  4. 4. Any surgeon who accepts the responsibility fordrainage of a hand infection must undertakecomprehensive management responsibilities including:  Preoperative Planning  Surgical Approach  Postoperative Care  Rehabilitation.
  5. 5. A. EvaulationB. Operative PrinciplesC. Rest/Heat/ElevationD. Inpatient Care
  6. 6. 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.
  7. 7.  SYMPTOMS: o Timing of events o Pain o Loss of function o Drainage o Fever o Chills.
  8. 8.  Physical Examination: o Exposure of whole extremity o Signs of lymphangitis and lymphadenopathy o A systemic approach to avoid missing critical information.
  9. 9.  RADIOGRAPHS: o Retained foreign bodies o Rule out osteomyelitis o Gas gangrene o Serve as baseline for future comparison.
  10. 10. A. EvaulationB. OPERATIVE PRINCIPLESC. Rest/Heat/ElevationD. Inpatient Care
  11. 11. 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.
  12. 12. 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.
  13. 13. A. EvaulationB. Operative PrinciplesC. REST/HEAT/ELEVATIOND. Inpatient Care
  14. 14. 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.
  15. 15. 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.
  16. 16. 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.
  17. 17. A. EvaulationB. Operative PrinciplesC. Rest/Heat/ElevationD. INPATIENT CARE
  18. 18. 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.
  19. 19.  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.
  20. 20. 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.
  21. 21. ACUTE PROCESSES: A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. Septic arthritisI. Necrotizing Fascitits.
  22. 22. A. CELLULITIS  Virtually all hand infections begin as cellutitis. Symptoms:  Pain  Swelling  Erythema  Lymphadenopathy  Lymphangitis.
  23. 23.  Treatment:  Oral antiboitics (usually gram +ve coverage)  Rest  Warm soaks  Elevation. LYMPHANGITIS > Cellulitis accompained by erythematous streaks up the arm.
  24. 24. ACUTE PROCESSES: A. CellulitisB. PARONYCHIAC. FelonD. Palmer space infectionsE. Pyogenci (Supparative) Flexor TenosynovitisF. Bite woundsG. Septic arthritisH. Necrotizing Fascitits.
  25. 25. B: PARONYCHIA Infection of the soft tissues surrounding thefingernail and is the most common infection ofhand.
  26. 26.
  27. 27.
  28. 28.  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.
  29. 29.  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.
  30. 30.  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.
  31. 31. ACUTE PROCESSES: A. CellulitisB. ParonychiaC. FELOND. Palmer space infectionsE. Pyogenci (Supparative) Flexor TenosynovitisF. Bite woundsG. Septic arthritisH. Necrotizing Fascitits.
  32. 32. C: FELON A felon is an abscess of the distal pulp of the thumb or finger.
  33. 33.
  34. 34.  Pulp Anatomy:  15-20 longitudonal septa anchoring skin to distal phalanx dividing the pulp into multiple closed compartments.
  35. 35.  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.
  36. 36.  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.
  37. 37.  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
  38. 38.
  39. 39. ACUTE PROCESSES: A. CellulitisB. ParonychiaC. FelonD. Herpetic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. Septic arthritisI. Necrotizing Fascitits.
  40. 40. 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.
  41. 41.
  42. 42.  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.
  43. 43.
  44. 44.  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%.
  45. 45. ACUTE PROCESSES: A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. PALMER SPACE INFECTIONSF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. Septic arthritisI. Necrotizing Fascitits.
  46. 46. 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.
  47. 47.  THENAR SPACE INFECTIONMIDPALMER SPACEINFECTION
  48. 48.  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.
  49. 49. 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.
  50. 50. 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.
  51. 51.
  52. 52. ACUTE PROCESSES: A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. PYOGENCI (SUPPARATIVE) FLEXOR TENOSYNOVITISG. Bite woundsH. Septic arthritisI. Necrotizing Fascitits.
  53. 53. 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.
  54. 54.
  55. 55.  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.
  56. 56.  < 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 .
  57. 57. ACUTE PROCESSES: A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. BITE WOUNDSH. Septic arthritisI. Necrotizing Fascitits.
  58. 58. G: BITE WOUNDS a) HUMAN BITESb) ANIMAL BITES
  59. 59. 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.
  60. 60.  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.
  61. 61. b. Animal bites: Domestic Dogs and CatsTetnus status should be ensured.Rabies prophylaxisThorough irrigation and exploaration of joints when potentially voilated.
  62. 62.  Acute DOG bites;  Sharpely debrided  Loosely approximated  Antiboitics / Rest / Heat / Elevation. Gram +ve and anaerobe coverage
  63. 63.  CAT bites can present late with closed space abscesses due to trapping of bacteria inside wounds
  64. 64.  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.
  65. 65. ACUTE PROCESSES: A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. SEPTIC ARTHRITISI. Necrotizing Fascitits.
  66. 66. 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.
  67. 67.  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
  68. 68.  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.
  69. 69. ACUTE PROCESSES: A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. Septic arthritisI. NECROTIZING FASCITITS.
  70. 70. I: NECTROTIZING FASCITIS  A life threatening, rapidly progressing infection of the subcutaneous tissue and fascia. Diabetics and immunocompromised patients are at greater risk.
  71. 71. Pathogenesis; Low grade cellulitis  bullous changes in skin cutaneous anesthesia with spread into underlying subcutaneous tissuefat necrosisvascular thrombosiMyonecrosiscutaneous vessel thrombosis.
  72. 72.  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.
  73. 73. CHRONIC INFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS
  74. 74. 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.
  75. 75.  Medical Management:  Topical antifungal  Topical steroids  Removal of thickened, deformed nail plate. Surgical Management:  Eponychial Marsupalization.
  76. 76. CHRONIC INFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS
  77. 77. 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.
  78. 78.  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
  79. 79.  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.
  80. 80. CHRONIC INFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS
  81. 81. 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.
  82. 82.  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.
  83. 83. CHRONIC INFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS
  84. 84. D: VIRAL INFECTIONS  Warts are viral infections caused by Human Papilloma Virus (HPV). Types of warts;1. Verruca vulgaris  95%  Rough  Raised cauliflowerlike appearance.2. Verruca plana  5%  Smooth  Minimally elevated.
  85. 85.  Treatment options; 1. Keratolytic  70% success rate  Duration several days to several weeks  Salicylic acid preparations 2. Cryotherapy  Liquid nitrogen  Without anesthesia  Warts refractory to conservative management.
  86. 86. 4. Surgical exicision  Excised with atleast 1mm margin.5. Laser ablation.6. Electrocautery7. Intralesional bleomycin or 5-flourouracil
  87. 87. CHRONIC INFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS
  88. 88. E: MYCOBACTERIAL INFECTIONS  Typically uncommon Typical (Tuberculosis) Mycobacterial Infections Atypical Mycobacterial Infections. MYCOBACTERIUM MARINUM

×