Hand infection is the infection caused in hand , since hand contains neurovascular bundles, muscles, bones, and ligaments. It includes 1. Acute Paronychia 2.Chronic Paronychia 3.Terminal pulp space infection ( felon) 4.subungal infection 5. Web space infecion 6. Mid palmar space infection 7.Thenar space infection 8. Deep palmar abscess 9. Acute suppurative tenosynovitis 11. Chronic Tenosynovitis 12. Lymphangitis of the hand 13. Arthritis of hand joints 14. Subcuticular abscess

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HAND
INFECTION

2. HAND INFECTION

3. HANDINFECTION
Definition
• Hand contains
neurovascular bundles,
muscles, bones and
ligaments.
• Infectionmay be due to
minor injuries or blood
borne.
PRICIPITINGCAUSES
• Diabetes
• Immunosuppression
• HIV infection
• Vascular diseases
COMMONORGANISMS
• Staphylococcus aureus-
most common – 90%
• Gram-negative organisms
like
• E. coli
• Klebsiella
• Pseudomonas

4. PATHOLOGY
Infectionspreads faster
↓
Causes oedema due to lax skin
↓
looks like frog hand
↓
Restricted movements of
fingers and hand.
↓
The handfunctions like hook,
pinch, grip, graspare lost.
SYMPTOMS
• Severe pain
• Tenderness withfever.
• Tender palpable
axillary lymphnodes
are oftenpresent

5. TYPESOF HANDINFECTION
1. Acute paronychia.
2. Chronicparonychia.
3. Terminal pulp space
infection(felon).
4. Subungualinfection.
5. Web space infection.
6. Mid-palmar space
infection.
7. Thenarspace infection.
8. Deep palmar abscess.
9. Acutesuppurative
10. tenosynovitis.
11. Chronictenosynovitis
12. Lymphangitis of the
hand.
13. Arthritis of hand joints.
14. Subcuticular abscess

6. INVESTIGATIONS
• Pus culture
• Blood sugar.
• Urine sugar and ketone
bodies.
• Arterial Doppler of the
handif needed.
TREAMENT
• Antibiotictherapy.
• Positionof rest with wrist
slightly abductedand
extended, thumb and
index fingers away (glass-
holding position).
REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das
Glass holding position

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PARONYCHIA

8. PARONYCHIA

9. ACUTE
PARONYCHIA
ACUTEPARONYCHIA
• (paronychiameans “Run
around”).
• It occurs in subcuticular
area under the
eponychium.
• Minor injuryto finger is
the common cause.

10. • Suppuration occurs very
rapidly.
• It tracks aroundthe skin
marginand spreads under
the nail causing hang nail
or floating nail.
CAUSATIVEORGANISM
• Staphylococcus aureus
• Streptococcus pyogenes.

11. CLINICALFEATURES
• Severe throbbing pain
• tenderness(dependent
throbbing)
• visible pus under the nail
root.
• Nail on touchis very tender
(paronychiameans “Run
around”).

12. TREATMENT
• Pus is sent for culture and
sensitivity.
• Antibiotics like cloxacillin,
amoxicillin.
• Pus is drained by making an
incisionover the eponychium
• Digital blockusing
xylocaine 2%plain
(withoutadrenaline as end
arterysupply to digits can
develop arterospasm) is
givenas anaesthesia

13. • If there is a floating nail,
thenthe nail is dead & it has
to be removed
• Recoveryis fast

14. CHRONIC
PARONYCHIA
FEATURES
• It is common in
females.
• Nail is diseased with
ridges and
pigmentation.
• Itching in the nail bed.
• Recurrent pain,
discharge
• Secondary bacterial
infectionmay
supervene

15. INVESTIGATION:
• Culture of scrapings
for fungus & other
causative agents.

16. TREATMENT:
• Long-termantifungal
therapy—local and
systemic.
• Antibiotics for
secondary infection.
• In severe cases removal
of nail is required

17. REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

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TERMINAL PULP
INFECTION
FELON

19. TERMINAL
PULP
INFECTION
FELON

20. TERMINALPULP INFECTION
FELON
• Felon is an abscessof pulp of
the finger
• It may involve the terminal,
middle or proximal pulp
space , sometimes distal pulp
space
• It is the secondmost
commonhand infection
(25%).
• Indexand thumb are
commonly affected.
• Usually by a minor injury
likefinger prick.

21. ORGANISMS
• Staphylococcus—most
common.
• Streptococcus, Gram-
negative organisms.
CLINICALFEATURES
• Pain, tenderness,
swelling in the
terminal phalanx.
• Fever.
• Tender axillarylymph
nodes.
• Oftensuppuration is
severe, forming collar
studabscesswhich
eventually may burst.
Staphylococus
Streptococus

22. INVESTIGATION
• X-rayof the part is
required oftento rule
out osteomyelitis of
terminal phalanx.
• Pus for culture and
sensitivity.
COMPLICATION
• Osteomyelitis of the
terminal phalanx.
• Pyogenicarthritis of
distal interphalangeal
jointand tenosynovitis
of flexor sheath.
• Septicaemia—in
immunosuppressed
individuals

23. TREATMENT
• Antibiotics and
analgesics.
• Drainage of terminal
pulp space by an
oblique deepincision.
• If there is osteomyelitis
of the terminal
phalanx, it has to be
amputated.

24. REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

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CORN

26. CORN

27. CORN
DEFINITION
• A Corn is thickenedskin on
thetop or side of a toe.
• They formto protect the skin
• They are two types
• The typeis determined by
theinner core , which canbe
soft or hard
TYPES
• Hardcorn.
• Soft corn.

28. Soft
• It usually occurs between
4thand 5th toes due to
friction of bases of
adjacentproximal
phalanges.
HARD
• It is localisedarea of
thickening over a bony
projec tions likeheads of
metatarsals.
• Histologicallyit differs from
callosityby having severe
keratoses witha central core
of degeneratedcells and
cholesterol.
• It presses over the adjacent
nerves causing pain.

29. • It can get infectedcausing
severe painand tender ness
with inability to walk.
• It is smaller lesion whichis
pusheddeepinto the skin
• Forming a localisedpalpable
painful/tender nodule with a
central yellow- white core of
deadcornifiedskin.

30. CLINICALFEATURES
• Corn is common if thereis
deformity or by wearing
tight fitting shoes/foot
wears.
• Corn is narrow, deep and
painful/tender.
• It is common in females.
• Corn is usually
white/gray/yellowcoloured,
deep seatedlesion
• Infection, abscess
formation and ulceration
can occur especially if
patient is diabetic.
• Cornmay be associated
with bursae causing
bursitis.
• Corn often recurs after
excision.

31. TREATMENT
• Excision.
• Local application of salicylic
acidpreparations or mixture
of salicylicacid/lactic
acid/collodionmay be
helpful.
• Skin softening agents are
also tried.
• Eliminating the pressure is
very important to prevent
recurrence.
Excisio
n

32. • Avoid excision of corn
unnecessarily in diabetic
(especiallywithneuropathy)
and in ischaemic foot.
REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das
Avoid excision –
Diabetic &
ischaemic foot

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INFECTION OF WEB
SPACE

34. INFECTION OF
WEB SPACE

35. INFECTIONOF WEB SPACE
CAUSES
• Abrasion.
• Infectionof proximal volar
space of finger.
• Callosities.
• Infectionof proximal
spaces.
• Trauma.
• Spread fromother palmar
spaces and fromflexor
sheaths throughlumbrical
canal.
Web space infections

36. CAUSATIVEORGANISM
• Staphylococcus.
• Streptococcus.
• Gram-negative
organisms.
CLINICALFEATURES
• Fever.
• Painand tenderness.
• Oedemaof dorsumof
hand.
• Maximumtendernessis
on the volar aspect.
• ‘V’ sign—separationof
fingers.
• If untreated, infection
may spreadinto other web
spaces and hand spaces.

37. TREATMENT
• Elevationof hand.
• Antibiotics and analgesics.
• Drainage under regional or
general anaesthesia.
• A horizontal incisionis
placed on volarskin of the
web and deepened to reach
thespace by dividing fibres
of palmar fascia.
• Pus is drained and sent for
culture and sensitivity.

38. • If other web spaces are
involved theyshouldbe
drained througha separate
incision.
• Edges of the wound are cut
to leave a diamondshaped
opening in front.
• Oftencounter-incision over
dorsal skin of web is
needed.
.

39. • Antibiotics and analgesics.
• Drainage of terminal pulp
space by an oblique deep
incision.
• If there is osteomyelitis of
the terminal phalanx, it has
to be amputated.
COMPLICATION
• Osteomyelitis of the
terminal phalanx.
• Pyogenicarthritis of distal
interphalangeal joint and
tenosynovitis of flexor
sheath.
• Septicaemia—in
immunosuppressed
individuals

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INGROWING TOE NAIL/
GROWING TOE NAIL
(Onychocryptosis)

41. INGROWING
TOE NAIL/
GROWING TOE
NAIL
(Onychocryptosis)

42. INGROWINGTOE NAIL/
ONYCHOCRYPTOSIS/
GROWINGTOE NAIL
(Onychocryptosis)
• It is also calledas embedded
toe nail.
• It is due to curling of the
side of nail inwards, causing
it to forma lateral spike
• resulting in repeated
irritationand infection of
overhanging tissues in the
nail fold.
CAUSES
• Tight shoes.
• Improper cutting of nails
(veryshort and convex).

43. CLINICALFEATURES
• It is commonin great toe
and is often bilateral.
• Bothmedial and lateral
sides of the toe can be
involved.
• Recurrent attacks of acute
and subacute paronychia
occurs.
• Pain
• Tenderness
• swelling of margins of the
toe
• oftenalong with
granulation tissue
• foul smelling discharge

44. TREATMENT
• Regular dressing and
packing.
• Antibiotics.
• Discharge is sent for culture
and sensitivity.
• Zadik’s or Fowler’s operation
• Nails should be cut concavely
or straight withoutleaving
lateral spikes towards soft
tissues. Zadik’s /
Fowler’s operation

45. • Antibiotics and analgesics.
• Drainage of terminal pulp
space by an oblique deep
incision.
• If there is osteomyelitis of
the terminal phalanx, it has
to be amputated.

46. COMPLICATION
• Osteomyelitis of the
terminal phalanx.
• Pyogenicarthritis of
distal
interphalangeal joint
and tenosynovitis of
flexor sheath.
• Septicaemia—in
immunosuppressed
individuals
Pyogenic arthritis
osteomyelitis
septicemia

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PALMAR SPACE
INFECTION/
MID PALMAR
INFECTION

48. PALMAR SPACE
INFECTION/
MID PALMAR
INFECTION

49. PALMAR SPACE INFECTION
MIDPALMAR INFECTION
CAUSES
• Trauma.
• Spread frominfection
of finger spaces and web
spaces.
• Haematogenous
spread.
• Spreadfrom
tenosynovitis

50. CLINICALFEATURES
• Painand tendernessin
the palm.
• Oedema of dorsumof
hand(frog hand).
• Loss of concavity of
palm.
• Painful movement of
metacarpophalangeal
joint(but
interphalangeal joint
movements are normal
and pain-free).

51. TREATMENT
• Elevationof the affected
limb.
• Antibiotics and analgesics.
• Drainthe pus
• Fever.
• Palpabletender axillary
lymph nodes.
• Eventually pus may come
out of palmar
aponeurosis forming
collar studabscess
• & later sinus formation.
Drain the pus by incision

52. REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgery by Das
3. A Concise textbookof
Surgery by Das
COMPLICATION
• Osteomyelitis of
metacarpals
• Stiffnessof hand
• Suppurative arthritis
• Extensionof infection
into other spaces.
Osteomyelitis of metacarpals

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PARANO INFECTION/
ACUTE SUPPURATIVE
TENOSYNOVITIS

54. PARANO
INFECTION/
ACUTE
SUPPURATIVE
TENOSYNOVITIS

55. PARANOINFECTION/
ACUTESUPPURATIVE
TENOSYNOVITIS
DEFINITION
• It is the bacterial
infectionof flexor
tendon sheaths
ORGANISM
• Staphylococcus aureus,
• Streptococcus
pyogenes.

56. CLINICALFEATURES
• Symmetrical swelling of
entire finger.
• Flexionof finger—Hook
sign.
• Severe pain on extension.
• Tendernessover the
sheath.
• Oedema of whole hand,
bothpalm and dorsum
(due to lymphaticspread).
• As ulnarbursa extends into
the little finger ,
• its infectionresults in pain
and tenderness extending up
to little finger but not much
to other fingers

57. • Kanavel signs
• Swollenfinger held in
flexion
• Exquisite pain on
passive extension
• Tenderness precisely
over the tendonsheath
• Area of greatest
tendernessoverthe
part of ulnar bursa
lying between
transversepalmar
creases.

58. Exquisite pain on
passive extension &
Swollen finger held in
flexion

59. • In infection of radial bursa
• thumb is swollenwith
painand tenderness
over the sheathof the
flexor pollicis longus
• &there is
inextensibilityof
interphalangeal joint.
• Swelling just above
the flexor retinaculum
is common.

60. TREATMENT
• Elevationof the affected
limb.
• Antibiotics and analgesics.
• Positionof rest.
• Drainageunder general
anaesthesia.
• Incisions are placed over the
site of maximumtenderness
and flexor sheathshouldbe
openedup.
• Many a times multiple
incisions are required.

61. COMPLICATION
• Spreadof infection
proximallyinto forearm-
to space of Parona
• Stiffnessof fingers and
hand
• Suppurative arthritis
• Osteomyelitis
• Mediannerve palsy
• Bacteraemia
• septicaemia
Suppurative arthritis
Median nerve palsy

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DUPUYTREN’S
CONTRACTURE

63. DUPUYTREN’S
CONTRACTURE

64. DUPUYTREN’S
CONTRACTURE
DEFINITION
• It refers to localised
thickening of palmar
aponeurosis and later
formation of nodules with
severe permanent changes
in metacarpophalangeal and
proximal interphalangeal
joints.
• It is common in males
• Terminal interphalangeal
jointis not involvedas
palmar aponeurosis does
not extend to terminal
phalanx.
DUPUYTREN’S
CONTRACTURE

65. COMMONSITE
• It starts in ringand little
fingers, withflexionof
ring and little fingers.
• Laterinvolving all fingers.
• There is thickening and
nodule formation in the
palmwith adherent skin.
• It is oftenfamilial and
bilateral 45%.
• Pads(of fat) develop in
knuckles and are called as
Garrod’s pads (in
proximal IP joints)
Garrod’s pads

66. AETIOLOGY
• Repeatedminor trauma,
use of vibrating tools.
• Cirrhosis
• Alcoholism
• smoking,
• Epileptics on treatment
with phenytoin sodium.
• Diabetics
• pulmonary tuberculosis,
• AIDS.
• Other metabolic
conditions.
• Familial—autosomal
dominant

67. .
ASSOCIATEDCONDITIONS
• Plantar fasciitis
• Ledderhose’s disease
• Mediastinal and
retroperitoneal fibrosis
• Peyronie’s disease of
penis
• Nodules in the face and
ear

68. • TRIAD- Galezia triad
• Dupuytren’s contracture
• Retroperitoneal fibrosis
• Peyronie’s diseaseof
penis.
Dupuytren’s
contracture
Retro
peritonealfibrosis
Peyronie’sdiseaseof
penis.
COMPLICATION
• Restriction of handfunction
and so disability.
• Arthritis of MCP &
proximal IP joints.
• Fasciotomy of palmar
aponeurosis and later physio
therapy, Z plasty.
• In severe cases fasciotomy
partial or complete.

69. TREATMENT
• Treat the cause.
RECURRENCE
• Recurrence can occur
in 5–50%cases.
REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

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VOLKMANN’S
ISCHMIC
CONTRATURE

71. VOLKMANN’S
ISCHMIC
CONTRATURE

72. VOLKMANNSISCHMIC
CONTRATURE
DEFINITION
• It is a vascular injury
leading to muscular
infarctionand subsequent
contracture.

73. CAUSES
• Supracondylar fracture of
the humerus.
• IV fluid
• chemotherapy.
• Burns.
• Closedforearmcrush
injuries.
• Tight plaster after reduction
of fracture.
Burns
Supracondylar fracture

74. PATHOGENESIS
• Injury to Brachial artery
• Followedby infarction of
forearm Flexor Muscles
• And injuryto mediannerve &
ulnar nerve bothby
ischaemia & infarction
• Followed by asepticmuscles
necrosis
• & fibrosis of flexor muscles of
forearmfollowedby
Contracture
Features

75. CLINICALFEATURES
• Acute phase:
• Pain(persistent pain
in forearm, hand,
fingers—ominous
symptom).
• Pallor
• Puffiness(due to
oedema).

76. • Pulseless(absence of
radial pulse; but its
presence does not rule out
theonset of impending
contracture).
• Paresis
• Late phase
• Deformity Deformity
(due to injury to
median nerve)
• Wrist joint extended.
• Extended
metacarpophalangeal
joints.
• Flexed interphalangeal
joints.
Pulseless

77. • Volkmann’s sign:
• In early stage, the
fingers can be
extendedat the
interphalangeal
joints, only when the
wrist is flexed fully.
• The fingers tendto
flex if any attempt to
extend the wrist is
made
Volkmann’s sign

78. TREATMENT
• In acutephase:
• Removal of plastic
cast appliedafter
fracture reduction.
• Correctionof
fracture.
• Exposure of brachial
arteryand
applicationof 2.5%
papaverine sulphate
to relieve the spasmif
any.

79. • Suture of arterial tear
if present, oftenwith
placement of arterial
graft.
• Lateral incisionover
the deepfascia of
forearmis placedto
decompress the
oedema.
• In late phase (once
deformity occurs):
• Physiotherapy
• Dynamicsplints.
• Max-Page operation:
Releaseof flexor muscles
(forearmmuscles) from
their origins fromthe
bone and allowing it
slidedown until full
extension.

80. MAX –PAGE OPERATION AFTER
MAX –PAGE OPERATION

81. • Excision of fibrous
tissue and damaged
muscles along with
tendon transfer.
• Arthrodesis.
REFERENCE
1. SRB's Manual of Surgery
by SriramBhatM
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

82. A
Special Thanks
To A Very
Special Doctor