Hand infections can be caused by bacteria such as Staphylococcus aureus entering through minor injuries or punctures. Common types of hand infections include paronychia (infection around the nail), felon (pulp space infection), and infections of the deep fascial spaces. Treatment involves antibiotics, drainage of pus if present, and immobilization. Complications can include tendon necrosis, skin loss, and joint stiffness if not properly treated.

3. HAND
INFECTIONS

4. OVERVIEW
Aetiology :
- Who?  manual workers & house-
wives
- 90 %  Staphylococcus aureus
Polymicrobial infections, Gram-
negative organisms and anaerobic
bacteria are documented
- Mode of entry  minor inj. &
punctures

5. (.OVERVIEW(CONT
C/P “in general” :
- Pain, swelling & fever .
- Site  according to point of max.
tenderness rather than area of
oedema !
Investigations:
- Plain X-ray  if F.B. is suspected
- Bl. Sugar testing  in recurrent
infections

6. (.OVERVIEW(CONT
 Treatment : (Generally)
1- Antibiotics are immediately started e.g.
Flucloxacillin, erythromycin, amoxycillin
clavulinic acid & 1st and 2nd generations of
cephalosporins. Gentamicin is added when
there is a history of injected drug use.
2- Elevation & if needed, immobilization in
position of function
3- Suppuration or No response to one day
intensive antibiotic therapy  Drainage of
pus. Drainage releases pus and improves the
venous return by decompressing the tension.

7. (.OVERVIEW(CONT
- Acute paronychia or Felon  local ring
anaethesia (without adrenaline) , general
anaethesia is preferred
- Tourniquet & Elevation  Bloodless field
- Appropriate skin incisions & sinus forceps
- C& S
- Soft rubber drains e.g. piece of surgical
glove
* Post-op. Elevation, Physiotherapy &
Dressing

8. CLASSIFICATION
 [I] Cutanous & sub-cutanous infections:
- Paronychia
- Pulp Space Infection (Felon)
- Web Space Abscess
 [II] Fascial spaces infection :
Deep Space Infection i.e. midpalmar space,
thenar space and Parona’s space.
 [III] Infection of the tendon with its
synovial sheath “tenosynovitis”.
 [IV] infection of the bone & joint (septic
arthritis).
 [V] miscellaneous infections.

9. SKIN INFECTIONS
Cellulitis and
Lymphangitis

10. PARONYCHIA
Anatomy

11. (PARONYCHIA (ACUTE
 Most common infection in the hand
Localized superficial infection or
abcess of the lateral nail fold
Typically is due to superficial trauma
(e.g. hangnails, nail biting,
dishwashing).
Paronychia in children often is the
result of finger sucking

15. PARONYCHIA (TREATMENT)
 Early Cellulitis
 Soaks, elevation, antibiotics
Fluctuant – all of the above, plus…
 Drain
May need anesthesia (digital block)
Soften by soaking
If severe infection with purulent drainage
beneath nail, requires removal of a portion
of the nail
 Follow up 24-48 h.
 Most resolve in 5-10 days

16. PARONYCHIA INCISION AND
DRAINAGE

17. OPERATIVE METHODS

18. (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.

19. A MODERATE PARONYCHIA. SWELLING AND REDNESS
AROUND THE EDGE OF THE NAIL IS CAUSED BY A
LARGE PUS COLLECTION UNDER THE SKIN.

20. ANOTHER VIEW OF THE SAME PARONYCHIA. THE
MAJORITY OF THE SWELLING AND REDNESS CAN
BE SEEN ON THE RIGHT SIDE OF THIS PICTURE.

21. A SCALPEL (KNIFE) IS INSERTED UNDER THE
SKIN AT THE EDGE OF NAIL TO OPEN THE
PUS POCKET AND DRAIN IT TO RELIEVE THE
PRESSURE AND TREAT THE INFECTION.

22. A CLOSER VIEW OF THE SCALPEL
USED TO OPEN THE INFECTED
AREA.

23. THE DOCTOR PUSHES ON THE SWOLLEN
AREA TO GET THE PUS OUT AFTER THE
INCISION WAS MADE WITH THE SCALPEL.

25. CHRONIC PARONYCHIA
Chronic Paronychia
of the Left Thumb
Recurrent paronychia
in the left index with
inflammation of the
nail folds. Recurrent or
chronic paronychia
may be a sign of poor
peripheral circulation
or lowered general
resistance.

27. PULP SPACE INFECTION
((FELON
 Anatomy :
The distal palmar phalanx is
compartmentalized by tangentially oriented
fibrous septa, resulting in a closed
compartment at the distal phalanx, which
helps prevent the proximal spread of
infection.
 Mode of infection :
Infection typically is due to direct
inoculation of bacteria by penetrating
trauma but may be caused by
hematogenous spread and by local spread
from an untreated paronychia.

28. PULP SPACE INFECTION
(.(CONT
 Paronychia may be present and/or it may be
a progression from paronychia
 C/P & Complications :
“Don’t wait for fluctuation”
-Infection results in edema and increased
pressure within the closed compartment. This
can impair venous outflow and lead to a local
compartment syndrome
- Invasion of the bone leads to osteomyelitis

30. PULP SPACE INFECTIONS
((FELON
Distal pulp space infection of the
right thumb (arrow) ‘Felon’, an
early case, with three days of
increasing throbbing pain.

31. OPERATIVE METHODS
 The best is a
longitudinal
incision over the
area of greatest
fluctuance.
 To avoid
penetration of the
tendon sheath, the
incision should not
extend to the distal
interphalangeal
crease.

32. HERPETIC WHITLOW
Herpes simplex virus (HSV) infection
of the distal finger typically results
from direct inoculation of the virus
into broken skin. Infection by type 1 or
type 2 HSV is clinically
indistinguishable. As in herpes
infections elsewhere in the body, it is
believed that the virus can remain
dormant in the neural ganglia, leading
to recurrent infections.

34. Herpetic whitlow in an infant with concomitant primary
herpes simplex virus (HSV) gingivostomatitis.

35. HERPETIC WHITLOW C/P
Incision is contraindicated as it spreads
the infection, unroofing relieves the pain
 Genital herpes in self or partner, Health care
workers and Children with gingivostomatitis
 Symptoms:
 Localized pain, pruritus, and swelling
followed by the appearance of clear vesicles
 Typically localized to 1 finger only (symptoms
involving more than 1 finger are more typical
of coxsackievirus infection)

36. HERPETIC WHITLOW C/P
(.(CONT
 Clear vesicles on an erythematous border
localized to 1 finger
 Pain, typically out of proportion to findings
 Edema
 Turbid or cloudy fluid in vesicles possibly
suggesting a superimposed pyogenic infection
 In later stages, coalescence of vesicles to form
an ulcer
 Distal finger pulp remains soft, distinguishes
HSV infections from bacterial felon
 Treatment is by dry gauze dressing

37. DEEP SPACE INFECTION
 These are infections in the potential deep
spaces of the hand, i.e. midpalmar space,
thenar space and Parona’s space.
 Parona’s space is deep in the distal forearm
between the pronator quadratus muscle
and the flexor digitorum profundus
tendons. This space is contiguous with the
radial bursa, ulnar bursa and midpalmar
space.
 Infections in these spaces may follow
haematogenous spread, penetrating injury
or rupture of pus from a
flexor tendon sheath.

38. FLEXOR TENDON SHEATH
INFECTION

39. PARONA’S SPACE INFECTION
 usually results from spread of infection
from the adjacent and contiguous
midpalmar space, or from the radial or
ulnar bursae. A flexor tendon sheath
infection may extend proximally to involve
the bursae and Parona’s space.
 There is swelling, tenderness, and
occasionally fluctuance of the distal volar
forearm. Digital flexion may be painful.

40. DEEP SPACES OF THE HAND

43. (DEEP SPACE INFECTION (C/P
 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 the middle and ring
fingers.
 In thenar space infections, the thenar
region is dramatically swollen and
exquisitely tender. The thumb is abducted
due to the increased pressure and volume
in the thenar space. Motion of the thumb
and index finger is painful.

44. THENAR SPACE INFECTIONS
Thenar space infection. Four
days after a puncture wound
of the thenar crease there is
pain, tenderness, swelling and
restricted movement. The
mid-palmar space was also
involved.

45. OPERATIVE METHODS
(A) Volar transverse approach
to the thenar space. Nerve
injury is a potential
complication. (B) Thenar crease
approach. Nerve injury can
result from this approach. It has
the added disadvantage of
limited drainage of the space
behind the adductor pollicis. (C)
Dorsal transverse approach. A
contracture of the web space
can result if this incision is
placed too close to the edge of
the web. (D) Dorsal longitudinal
approach to the thenar space.

46. MIDPALMAR SPACE INFECTIONS
Collar stud abscess
resulting from stabbing
of the thenar crease
with an indelible pencil.
The deep component of
this abscess was in the
midpalmar space which
became tender and
swollen. The middle
finger is flexed because
of involvement of its
tendon sheath.

47. OPERATIVE METHODS
(A) Transverse distal
palmar exposure of the
midpalmar space. (B)
Approach to the
midpalmar space
through the lumbrical
canal. (C) Combined
longitudinal and
transverse approach.
(D) Longitudinal
approach to the
midpalmar space.

48. HYPOTHENAR SPACE
INFECTIONS
Approach to the
hypothenar space

49. WEB SPACE “COLLAR BUTTON”
ABSCESS
A dorsal thenar web
space infection

51. OPERATIVE METHODS
(A) Curved longitudinal volar incision for drainage of a web , (B) Dorsal
incision used in conjunction with A. (C) Volar transverse incision, can
cause web space contracture. (D) Volar exposure, used with dorsal incision
B.

52. DORSAL SPACE INFECTIONS
Fig. : A deep dorsal
Fig. : Dorsal subcutaneous
(subaponeurotic) space
space infection following a bite
infection in an elderly diabetic.
over the metacarpo-phalangeal
This abscess burst
joint of the ring finger. There is
spontaneously and discharged
extensive dorsal swelling.
foul smelling pus.

53. PYOGENIC FLEXOR
TENOSYNOVITIS
Fig. : Testing for local Fig. : Testing passive extension of the
fingers. The hand rests on a table and
tenderness over the gentle passive pressure is applied to the
proximal end of the flexor fingernail. In a patient with septic
tendon sheath with a probe tenosynovitis such minimal movement
or swab stick. of the flexor sheath produces exquisite
pain.

54. OPERATIVE METHODS
Incisions for drainage of tendon
sheath infections. (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.

55. ULNAR AND RADIAL BURSA
INFECTION
 The radial bursa is a continuation of the flexor
pollicis longus tendon sheath through the flexor
retinaculum to a level 2.5 cm above the wrist joint.
 The ulna bursa arises from the sheath of the fifth
digit and joins the common flexor sheath at the
wrist. It too passes through the flexor retinaculum
to end 2.5 cm above the wrist.
 Hence ,infection of both 'bursa' may result from
direct spread proximally along the associated
tendon sheath or from a penetrating injury.
 Treatment is similar to that recommended for
tendon infections: open or closed irrigation,
leaving a drain in situ and antibiotic cover

57. OSTEOMYELITIS
Fig. : Acute
osteomyelitis. Five weeks
after penetration and
infection of the lateral
pulp space, the thumb
pulp remained painful,
tender and slightly
swollen.
Fig. : X-ray rarefaction
of the distal phalanx.

58. PYOGENIC ARTHRITIS
Septic arthritis occurring
three weeks after a bite
wound to the dorsal
aspect of the proximal
interphalangeal joint. The
finger became
increasingly painful until
pus discharged. Bite
wounds are often
complicated by severe
infection.

59. CHRONIC INFECTIONS
 Atypical Mycobacterial infections
 Tuberculosis
 Leprosy
 Fungal infections
 Viral infections
 Algal, protozoan, and parasitic infections

61. COMPLICATIONS OF HAND INFECTIONS
1- Necrosis of Tendons
2- Skin Loss
3- Secondary Haemorhage
4- Persistent Oedema
5- Lymphangitis
6- Stiffness, Ankylosis and Contractures
7- Osteomyelitis and Septic Arthritis