The document discusses hand infections, including their history and treatment principles. It covers topics like felons, paronychia, tenosynovitis, and other specific types of hand infections. Some key points: - Prior to antibiotics, many hand deformities and disabilities resulted from minor injuries becoming infected. Careful surgical techniques helped treatment. - Penicillin revolutionized treatment by making severe infections less common today. Early diagnosis and treatment with antibiotics, splinting and elevation can help cure some infections. - Surgical drainage and debridement may be needed for established infections to prevent complications like joint stiffness or contractures. Appropriate antibiotic use and incision placement are important for optimal outcomes.

2. Hand Infections

3. 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

4. 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)

5. Hand Infections
Outline
 Principles
 High Risk Patients
 Felons & Paronychia
 Flexor Tenosynovitis
 Deep Space Infections
 Bites
 IDU
 Osteomyelitis
 Septic Arthritis
 Chronic Infections

6. 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

7. 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

8. 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

9. 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

10. Felons & Paronychia
General
Account for ~ 1/3 of hand infections

11. 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.

12. 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

13. 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

14. 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

15. Felons
Treatment
Palmar 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

16. Felons
Treatment
Unilateral 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

17. Paronychia
Anatomy

18. 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”

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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)

31. Deep Space Infections
 4 deep spaces clinically significant in hand infections:
 Subfascial palmar space
 Dorsal subaponeurotic space
 Thenar space
 Midpalmar space

32. 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

33. 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

34. 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

35. 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

36. 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.

37. 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

38. 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

39. Deep Space Infections
Midpalmar Space Infections
 Clinical:
 usually due to direct penetrating trauma, rupture of tenosynovitis
 loss of palmar concavity, dorsal swelling, tenderness volarly

40. 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.

41. 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

42. Bursal Infections
Treatment
 Closed irrigation using 2 incisions, a catheter & a drain as
previously outlined.

43. 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

44. 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)

45. 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

46. 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)

47. 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

48. 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

49. 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.

50. 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

51. 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

52. 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

53. 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

54. 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)

55. 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

56. 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

57. 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

58. 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.