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1. HandInfectionsKeerati Supsaman R2.

2. Overview
• Hand Anatomy
• Acute/chronic Paronychia
• Felon
• Herpetic whitlow
• Flexor Tenosynovitis
• Deep space palm infection
• Animal bite
• Human bite

3. Fibrous digital sheaths
• Ligamentous tubes that enclose
– Synovial sheaths
– Superficial and deep flexor tendons
– Tendonsof Flexor policis longus

5. Deep space of hand.

9. Schwartz’s Principles of surgery, 9th edition

10. Acute Paronychia

11. Paronychia
• Infection of the lateral nail fold
• If Infection extends to the eponychium
(defined as the thin membrane distal to the
nail wall at the base of the nail), it is properly
termed an eponychia.
• When infection involves both lateral nail folds and
eponychium, it is called a run-around infection
• Infection occurs when there is violation of the seal
between the nail plate and nail fold, allowing the
inoculation of bacteria.

13. Risk Factors
– Hangnails,
– Manicures,
– Penetrating trauma,
– Constant exposure to a wet
or moist environment,
– Nail biting or sucking

14. Treatment
Non surgical
– Oral antibiotics,
– Warm soaks
– Rest and observation

16. A: An infected lateral and proximal nail fold can be elevated by an elevator or scalpel. B:
For extensive infections, a relief incision(s) is made perpendicular to the edge of the nail
fold to allow for removal of a portion or all of the nail plate. (Reprinted from Seiler JG.
Essentials of hand surgery . Philadelphia: Lippincott Williams & Wilkins, 2002, with
permission. Copyright American Society of Surgery of the Hand.)

19. (A) Elevation of the eponychial fold with flat probe to expose the base of
the nail. (B) Placement of an incision to drain the paronychium and to
elevate the eponychial fold for excision of the proximal one-third of the
nail. (C-E) Incisions and procedure for elevating the entire eponychial
fold with excision of the proximal one-third of the nail. A gauze pack
prevents premature closure of the cavity.

20. • Chronic paronychia
• Chronic paronychia occurs more commonly in
individuals
constantly exposed to moist environments.
• Infections may be intermittent; clinically, the
eponichial fold is thickened and painful
• Candida albicans is a frequent
offending organism
• Topical antifungal ointments are
generally used 4 to 6 weeks.

22. Felon

23. • A felon is a deep space infection or
abscess of the distal pulp of the
finger or thumb.
• The organism most frequently
cultured from a pulp space
infection is S.Aureus[direct
trauma]
• local spread from an untreated
paronychia. Or hematogenous
Felon
• Throbbing pain and
• Tense swelling localized to the pulp

24. “Don’t wait for fluctuation if tension is severe”
• Invasion of the bone may leadto osteomyelitis
Infection edema
increase
pressure
in closed
space
Impaired
venous
flow
Compart
ment

25. FIGURE 7. Incisions used for decompression of a felon. A: A
midlateral incision is preferred. B: A J-shaped or hockey-stick
incision. C: A through-and-through incision. D,E: A volar transverse
or longitudinal incision.
Treatment : Surgical decompression

26. Herpetic Whitlow
– Typicallylocalized to 1finger only (symptoms involvingmore than 1finger are more typical ofcoxsackievirus
infection)

27. Herpetic whitlow
• Herpetic whitlow is an intensely painfulinfection
of the hand involving 1 or more fingers that
typically affects the terminalphalanx.
– Commonly involves thumb and indexfingers
Riskfactors
• Genital herpes in self orpartner.
• Health careworkers
• Children with gingivostomatitis

28. Herpetic whitlow
• The diagnosis can be confirmed by a Tzanck test, which
demonstrates the presence of multinucleated giant cells in a
scraping taken from the base of an unroofed vesicle.
Treatment
• Self limited disease
• Incision is contraindicated as it spreads the infection may lead to
herpetic encephalitis
• Unroofing relieves the pain

29. Pyogenic Flexor Tenosynovitis
• The flexor sheath is an
intricate continuous
synovial sheath originating
at the level of the
metacarpal neck and
ending at the insertion of
the flexor digitorum
profundus.

32. Clinical presentation
• Kanavel's four cardinal signs:
– tenderness along the flexor sheath
– a semiflexed resting posture of the
involved digit
– symmetric digital swelling (sausage
digit),fusiform swelling
– pain with passive extension of the digit
(the most reproducible clinical sign),
*Not all signs may be present

34. Clicinal relevance
• The radial and ulnar bursa can communicate at
the level of the transverse carpal ligament
through Parona's space producing a
horseshoe abscess.

35. . (A) Open drainage incisions. (B) Single incision for instillation therapy of tendon
sheath infection. (C) Sheath irrigated via needle proximally and single distal incision.
(D) Incisions for through-and- through intermittent irrigation. (E) Closed tendon
sheath irrigation technique.
(F) Closed irrigation of ulnar bursa.
Treatment:
Incisions for drainage of tendon sheath.

36. Deep space palm infection

37. Deep space palm infection
• Palmar space infection
• Thenar space
• Midpalm space
• Hypothenar space
• Deep subfascial space infection
• Dorsal subcutaneous space
• Dorsal subaponeurotic space
• Interdigital web space

40. Web space infections
• Communication:
–Palmar surface contiguous
with dorsalsubcutaneous
Borders:
–Dorsal / Volar
• Dorsal hand fascia
• Palmar fascia
Radial/Ulnar
Digital extensor
mechanisms and
MCPjoint
structures
–Distal
Vertical septae of
palmar aponeurosis,
approx. 2cmproximal
to interdigitalwebs

41. Web space infections
• Also known as a collar button
abscess or hourglass
abscess.
• Involves the subfascial palmar
space between the digits
• An abscess subsequently
develops and extends either
volarly or usually dorsally to
include the contiguous
subcutaneous space of the
dorsal hand

42. • Incisional drainage is performed with separate dorsal or volar or
combined approaches .
• Atransverse incision in the web space itself should be avoided to
prevent possible web space scar contracture .
Treatment

44. Dorsal SubaponeuroticSpace Infections

45. In midpalmar space infections, the
hand loses its normal palmar
concavity with tenderness and
induration over the palm. There is
dorsal hand swelling and limited and
painful motion of themiddle and ring
fingers
In thenar space infections, the thenar
region is dramatically swollen and
exquisitely tender. Thethumb is
abducted due to the increased pressure
and volume in the thenarspace.Motion
ofthe thumb and index finger is painful.

46. Animal and human bite.
clenched fist injuries
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