Hand Infections by Dr Rogers Ntambi. This power point presentation is about infections of the hand, relevant anatomy, epidemiology, investigations and treatment options. The deep palmar infections, webspace, space of parona and other hand infections have been included. Some atypical hand infections have also been included Plastic surgery and Orthopedics surgery approaches have also been shown.

1. Hand Infections
Presenter
Dr Ntambi Rogers
Othorpaedics Surgery

2. Objectives
• Relevant anatomy
• Epidemiology
• Etiology
• Clinical presentation
• Investigations
• Management
• Common hand infections

3. Relevant anatomy
• The anatomical complexity of the hand and delicate function, requires
characterization of the specific structures involved.
• Hand infections may broadly be characterized as being superficial or
deep

4. Anatomy
• Deep spaces include the dorsal subaponeurotic, the thenar, the midpalmar,
Parona’s quadrilateral, and interdigital subfascial web space
• Thenar space
• A bursa adductor pollicis dorsally, the index finger flexor tendon volarly,
the adductor pollicis insertion on the proximal phalanx radially
• Midpalmar space
Located dorsal and radial to hypothenar space
Dorsal borders; long and ring finger metacarpals and the interosseous
muscles;
The volar borders are the flexor tendons and the lumbrical muscles

5. Anatomy
• Hypothenar space;
• Located palmar to fifth metacarpal, dorsal and radial to hypothenar
fascia, ulnar to hypothenar septum

6. Epidemiology
• 70% to 85% of hand infections are located within the skin, nail fold,
fingertip pulp, or subcutaneous tissues
• Manual laborers are more predisposed to superficial trauma
• Intravenous drug users, diabetics, and immunocompromised patients
are other subpopulations identified as being at greater risk
• Compared to a healthy patient population, diabetic patients are at
greater risk

7. • Elderly patients are at a higher risk due to an increased burden of
comorbidity, weakened skin barrier and more poor vascular perfusion
in the distal extremities

8. Etiology
• Infections of the hand may arise in a myriad of ways, but frequently
due to direct inoculation and contiguous spread to adjacent
structures after a traumatic injury.
• Delayed or inadequate treatment after minor trauma.
• Infections may also spread hematogenously.
• Numerous bacterial and fungal pathogens have been isolated,
Staphylococcus aureus being cited as the commonest followed by
Streptococcus species.

9. • Chronic paronychia in patients working in wet environments is
commonly determined to be caused by Candida albicans.
• Atypical infections with nontuberculous mycobacterial species, such
as Mycobacterium marinum

10. History and Physical
• History and physical exam is necessary to determine the correct
diagnosis and necessary treatment.
• It is important to determine the patient’s age, handedness, and
occupation.
• Comorbidities and past medical history should be obtained as certain
medications.
• Understanding the chronicity and the setting of inoculation will help
to guide empiric antibiotic coverage

11. • Patients should also be assessed for signs of nerve compression.
• Noting the presence of crepitation may suggest an infection with a
gas-forming microorganism

12. Evaluation
• Laboratory evaluation should include assessment of the white blood
cell count and inflammatory markers.
• Blood, and local fluid or tissue cultures can also be acquired to
identify the responsible organism and evaluate for antibiotic
susceptibility.
• Radiographs can be assessed for osteolysis or periosteal reaction if
osteomyelitis is ,presence of radiolucent foreign bodies which can
serve as a nidus for infection.
• Ultrasound, computed tomography (CT) scan, or magnetic resonance
imaging (MRI) may be used to identify and localize abscesses.

13. Treatment / Management
• Treatment of hand infections is specific to the particular pathology,
• Conservative management of infections includes splint
immobilization, soaks, and elevation in addition to adequate
antimicrobial coverage.
• Broad-spectrum antimicrobial coverage should be started while
awaiting objective culture data.
• Empiric antibiotic selection should include coverage against Gram-
positive, Gram-negative, and anaerobic organisms

14. • Deeper infections more frequently require intravenous antibiotic
treatment and prompt surgical management.

15. Prognosis
• The prognoses of hand infections depends upon the pathology and
treatment by the physician.
• Provided the infection is promptly recognized, appropriate
antimicrobial coverage initiated early, superficial infections typically
resolve with good functional outcome.
• In cases of infections involving deep structures, the prognosis
depends upon the chronicity of infection, the respective structures
involved, and the adequacy of surgical and antimicrobial treatment.

16. • With deeper infections, postoperative care, and structured hand
therapy are paramount to minimize tendon adhesions and digital
stiffness.

17. Complications
• If unrecognized or inadequately treated, infections may progress to
involve contiguous structures, resulting in greater morbidity to
patients.
• Functional limitations and neurovascular compromise may arise as a
result of mismanagement.
• Other complications include stiffness, tendon rupture, joint
destruction, osteomyelitis, nerve compression, and wound
complications requiring amputation or flap.

18. Human Bites
• Most septic and most serious bite
• Mixed flora – extremely pathogenic to normal tissue
• Tips of fingers, knuckles
• “ Fight bite” –
• Attacker with finger in full flexion
• Presents as patient fingers in extension
• Superficial puncture wound
• Much deeper into MP joints – “closing off “

19. Human bites
• Treatment aggressive – debridement wide A/B :
• Triple therapy – Penicillin, Aminoglycoside, Metronidazole
• Can still cause osteomyelitis
• Sometimes partial amputation only way to stop spread of infection

20. Cat bite
• : - Consider pasteurella multocida; note P. multocida infection
develops within 24hrs;
• - Pith bites on the finger observe for osteomyelitis;
• - Pay transmit tularemia and rabies;
• - Prophylactic treatment: augmentin / amoxicillin or with
allergy (cipro + clindamycin)
• - w/ estabilished infection: unasyn or with allergy (cipro +
clindamycin) or ceftriaxone

21. Dog bite:
• - Consider viridans strep, pasteurella multocida
• - Prophylactic treatment: augmentin / amoxicillin or with allergy
(cipro + clindamycin)
• Consider antirabies rx; rabies immune globin + vaccine;
•

22. DOGBITE

23. DOGBITE

24. Septic Arthritis
• Should be distinguished from gouty arthritis
• Arthrotomy and debridement
• Synovectomy and irrigation
• Appropriate A/B
• Joint mobilization

25. Necrotizing Fasciitis
• Causitive organism : Clostridia family – mostly Perfringens
• Sometimes Streptococci
• Overwhelming, fast spreading, with systemic toxic symptoms
• Radical surgical debridement and re-debridement
• IV A/B : Start on high doses Penicillin

26. Necrotizing Fasciitis

27. Pyogenic Granuloma
• Overgrowth of granulation tissue
• Chemical cauterization :
• Silver Nitrate
• Iodine
• Surgical removal and skin grafting
• Send for histology

28. Postoperative Wound Infection
• Prevention :
• Aseptic techniques
• Gentle tissue handling
• Preservation of blood flow
• Prevention of oedema
• Treatment :
• Removal of sutures
• Hand baths
• A/B

29. Paronychia
• Diagnosis involves careful clinical examination assessing for
erythema and fluctuance around the nail bed with
discoloration/hypertrophic changes of the nail.
• Treatment involves warm soaks and oral antibiotics and if fluctuance
is present, debridement and partial/complete nail removal is
warranted.

30. Paronychia
• Early stages –
elevation and A/B
• Collection of pus –
drained
• Remove lateral
aspect of nail – can
form sequestrum
• Osteitis

31. Pulp space infection (Felon)
• Abscess of the distal pulp or
phalanx pad of the fingertip

32. Felon
• Usually penetrating trauma
• Most commonly affected digits are the thumb and index finger
• May arise when an untreated paronychia spreads into the pad of the
fingertip.

33. Felon

34. Herpetic Whitlow
• Results from autoinoculation of type 1 or type 2
herpes simplex virus into broken skin.
• The infection may occur as a complication of primary
oral or genital herpes lesions.
• Health care workers exposed to oral secretions

35. Palmar space infections
• 3 Potential Spaces
• Thenar Space
• Mid-palmar Space
• Parona’s Space

36. Palmar Space Infections
• Webspace, thenar or midpalmar
• Cause :
• Septic callus, septic blister, tenosynovitis, direct inoculation
• Treatment :
• Approach webspaces directly
• Blunt dissection
• Evacuate the abscess

37. Incisions

38. Mid palmar space incisions
A, Distal longitudinal palmar incision. B, Transverse palmar
incision. C, Extended longitudinal palmar incision

39. Thenar space incisions
A, Thenar crease incision (palmar). B, Dorsal longitudinal
incision.

40. Web Space Infection (Collar Button Abscess)
• Web space infection usually localizes in one of the three fat-filled
interdigital spaces.
• Typically, the infection begins beneath palmar calluses in laborers.
• It may begin near the palmar surface, but because the skin and fascia here
are less yielding, it may localize to drain dorsally
• This may be the more dangerous part because, unless drained, it may
spread through the lumbrical canal into the middle palmar space.
• Two longitudinal incisions usually are necessary for drainage: one on the
dorsal surface between the metacarpal heads and the other on the palm,
beginning distal to the distal palmar crease and curving proximally.
Crossing the palmar creases at right angles to the crease should be avoided

41. Webspace incisions

42. Septic Tenosynovitis
• Serious infection
• Massive oedema of finger
• May spread via synovial sheaths
• Kanavel’s four cardinal signs
• Early incision and irrigation
• Hand is elevated
• Mobilization is delayed for 3-4 days

43. Kanavel’s four signs
• Slight flexion of finger
• Swelling
• Pinpoint tenderness over sheath
• Pain on passive extension

44. Flexor tendon sheaths drainage incisions

45. • Usually secondary
trauma or puncture
wound.
• The trauma often is at a
flexor crease; this is
where the tendon
sheath is most
superficial.

47. Paron’s Space
• Potential space between FPL tendon, FDP tendons, & pronator
quadratus;
• - is known as the subtendinous space of the wrist or Parona's
space;
• Pus in FPL sheath can ascend in the radial bursa and eventually
rupture into this space.
• Pus in little finger sheath can ascend in ulnar bursae & rupture into
Paron's space;

48. • Pus from either the radial or ulnar bursae ruptures into Parona's
space, it can be drained by the same incision used for releasing pus
from the proximal end of the ulnar bursae.

50. Fungal Infections
• Fungal Infections of the hand are usually mild and are broken into 4 types:
cutaneous, subcutaneous, deep.
• Onychomycosis is more common in middle-aged women
• Risk factors
• More common to have fungal infection in macerated skin areas (skin
folds)
• Candida more prevalent in patients working in moist environments or
under water.
• Immunocompromised patients at risk for Deep infections

51. Onychomycosis
• Defined as fungal infection in vicinity of nail bed (cutaneous)
most common organisms are trichophyton rubrum and candida
• It’s a destructive nail plate infection chronic infection of nail fold
• Treatment
• topic antifungal treatment & nail plate removal
• indications
• first line of treatment
• systemic griseofulvin or ketoconazole
• indications
• recalcitrant cases

52. Onychomycosis

53. Leprosy
• Staged and rare infection
• Inflammatory stage – leads to an absolutely stiff hand
• High doses Cortisone
• Loss of sensation – burns and injuries
• Osteomyelitis can follow
• Drugs : Dapsone, Rifampicin, Clofazimine

54. Tuberculosis
• Not uncommon in the wrist joint
• Diagnosis difficult
• Mostly confirmed with synovial biopsy
• Treatment :
• Synovectomy
• Splintage
• Rehabilitation
• Drug regime

55. Dorsal Incisions

56. [Reference list]
• Orthobullets
• Wheeless' Textbook of Orthopaedics
• Rerucha CM, Ewing JT, Oppenlander KE, Cowan WC. Acute Hand
Infections. Am Fam Physician. 2019 Feb 15;99(4):228-236. [PubMed]
• Koshy JC, Bell B. Hand Infections. J Hand Surg Am. 2019 Jan;44(1):46-
54. [PubMed]
• Rigopoulos N, Dailiana ZH, Varitimidis S, Malizos KN. Closed-space
hand infections: diagnostic and treatment considerations. Orthop Rev
(Pavia). 2012 May 09;4(2):e19. [PubMed] [Reference list]

57. THANK YOU