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Hand infections
- 1. Hand infections Dr VivekSingh 23/4/2017
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- 3. Paronychia Infection ofthe lateral nail fold Most common Eponychia Run-around infection
- 4. Paronychia Staph aureusmost common although most are mixed Violation of the seal between nail plate and nail fold Risk Factors Hangnails, Manicures, Penetrating trauma, Constant exposure to a wet environment, Nail biting or sucking
- 5. Swelling, erythema & tenderness with progressio n to abscess formation. Spontaneous decompression canoccur, (subungual abscess). Deeper infections can involve the nailbed, pulp space, and bone Paronychia-Clinical presentation
- 6. Paronychia Laboratory evaluationif not responding to initial treatment Radiographs if long-standing infection, foreign body or osteomyelitis
- 7. Paronychia-Treatment Early stage Oralantibiotics, Warm soaks in Povidone-iodine Rest and observation Surgical decompression Keep blade away from nail bed A small wick is placed for 24 to 48 hours
- 8. Paronychia-Treatment Infection thattravels below the nail plate - remove a portion of the nail. If the entire nail matrix is involved,then the entire nail is removed.
- 9. Chronic Paronychia Indurated,painful eponychium Frequent water immersion-predisposing Intermittent acute infections Diabetes and psoriasis predisposing Gram-positive,negative, Candida,mycobacterial
- 10. Chronic Paronychia Marsupialization Nail removal if deformed Protect the germinal matrix Oral antibiotics for 2 weeks Change if Mycobacterial Early finger ROM
- 11. Felon ◦ Deep spaceinfection of the distal pulp ◦ Differs from apical infections ◦ Multiple septal compartments ◦ Most frequent S. Aureus ◦ 15% to 20% of all hand infections.
- 12. Felon Penetrating trauma Hematogenous spread Finger stick felon Most common in thumb & index finger. Throbbing pain Tense swelling localized to the pulp
- 13. Felon Extend towardthe phalanx --> osteomyelitis Toward the skin --> draining sinus Obliterate vessels ---> skin slough or necrosis Suppurative flexor tenosynovitis Septic arthritis of the DIPJ
- 14. Felon-Treatment Aim-Preserving thefunction of distal phalanx. Don’t wait for fluctuation if tension is severe If recognized early (mild cellulitis): soaks & antibiotics Abscess(48 hrs): surgical drainage
- 15. Felon-Treatment Principles Avoidinjury to nerve and vessels Don’t leave a disabling scar Do not violate flexor sheath Produce adequate drainage Keep wound open
- 16. Pyogenic Flexor Tenosynovitis Synovial sheath Extend from the mid-palmar crease to the DIPJ (A1 to A5) Small finger-Ulnar bursa Thumb sheath-Radial Bursa Parona space
- 17. Pyogenic Flexor Tenosynovitis Penetrating trauma Felons can rupture Purulence destroys the gliding mechanism Tendon necrosis possible Usual causative agent: Staph. Aureus Pasteurella multocida -animal bites. Immunocompromised -Mixed gram –and+
- 18. Kanavel’s 4 cardinalsigns Severe pain on passive extension of the finger (most reliable) Kanavel A: Infections of the Hand. 7th ed. Philadelphia, Lea & Febiger, 1939.
- 19. Pyogenic Flexor Tenosynovitis-Treatment Early infection < 48 hrs- IV Abx, splinting & elevation Failure to respond within 24 hr - drainage Established pyogenic tenosynovitis is a surgical emergency
- 20. Treatment 2 basicapproaches: Open vs. Closed
- 21. Closed tendon sheathirrigation
- 22. Deep Space Infections Hand-three potential palmar spaces. Forearm has one potential space. Hand-three superficial spaces
- 23. Deep Space Infections Swelling particularly on the dorsal side. Distinguish from local dorsal abscess X-Ray for retained foreign body, OM, or fracture. Aspiration, ultrasound, or MRI may be useful .
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- 25. Thenar Space Infections •Most common of deep space infection • Cause-Penetrating injury • Thumb or index subcutaneous abscess • Thumb or index flexor tenosynovitis • Extension from radial bursa or midpalmar space
- 26. Thenar Space Infections •Marked swelling • Thumb forced into abduction • Severe pain with extension or opposition • Infection tracks dorsally -Dumbbell or Pantaloon abscess
- 27. Thenar Space Infections-Treatment Treat as a surgical emergency Drain via volar or dorsal incisions or both Identify neurovascular structures Irrigate & debride Close over drain Compressive dressing & plaster splint
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- 29. Midpalmar Space Infections Directpenetrating trauma, Rupture of septic tenosynovitis Loss of palmar concavity, Dorsal swelling, Pain on passive extension
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- 31. Deep Subfascial SpaceInfections 1. Dorsal subcutaneous space 2. Dorsal subaponeurotic space 3. Interdigital web space-collar-button abscess
- 32. Deep Subfascial SpaceInfections Dorsal Subcutaneous and Dorsal Subaponeurotic Space Abscess Penetrating injuries Dorsal aspect of the hand swollen,warm and tender. Finger extension difficult and painful. Differentiating from cellulitis or other hand infections difficult
- 33. Deep Subfascial SpaceInfections Web Space Abscess (Collar-Button Abscess) Hourglass shape Cause-fissure in the skin between the fingers Pain and swelling localized to the web space Swelling either palmar or dorsal aspect Finger abduction
- 34. Deep Subfascial SpaceInfections- Treatment Dorsal Subcutaneous and Subaponeurotic Space Abscess One or two dorsal longitudinal incisions Determine whether infection is superficial or deep Subaponeurotic space opened by incising along margin of the extensor tendon
- 35. Deep Subfascial SpaceInfections Collar-Button Abscess Most important aspect-Treat both dorsal and volar components Both dorsal and volar incisions
- 36. Deep space infections-Aftertreatment Keep wounds open Gauze wick for 48-72 hrs After 72 hrs soaks in Povidone-iodine IV Antibiotics 10 days Oral antibiotics 4 weeks Early active motion
- 37. Summary Careful history& examination Anatomical area involved Extent of spread Empiric antibiotics till culture report Prompt and adequate surgical treatment Immobilization in position of function Rehabilitation
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