Hand infections


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Hand infections

  1. 1. Hand Infections
  2. 2. 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
  3. 3. 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)
  4. 4. Hand Infections Outline Principles High Risk Patients Felons & Paronychia Flexor Tenosynovitis Deep Space Infections Bites IDU Osteomyelitis Septic Arthritis Chronic Infections
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. Felons & Paronychia GeneralAccount for ~ 1/3 of hand infections
  10. 10. 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.
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. Felons TreatmentPalmar 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
  15. 15. Felons TreatmentUnilateral 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
  16. 16. Paronychia Anatomy
  17. 17. 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”
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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)
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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)
  30. 30. Deep Space Infections 4 deep spaces clinically significant in hand infections:  Subfascial palmar space  Dorsal subaponeurotic space  Thenar space  Midpalmar space
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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.
  36. 36. 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
  37. 37. 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
  38. 38. Deep Space Infections Midpalmar Space Infections Clinical:  usually due to direct penetrating trauma, rupture of tenosynovitis  loss of palmar concavity, dorsal swelling, tenderness volarly
  39. 39. 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.
  40. 40. 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
  41. 41. Bursal Infections Treatment Closed irrigation using 2 incisions, a catheter & a drain as previously outlined.
  42. 42. 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
  43. 43. 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)
  44. 44. 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
  45. 45. 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)
  46. 46. 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
  47. 47. 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
  48. 48. 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.
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. 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)
  54. 54. 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
  55. 55. 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
  56. 56. 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
  57. 57. 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.