Infections of hand

1. Infections of the Hand

2.  INTRODUCTION
 ANATOMY OF HAND
 CLASSIFICATION OF INFECTIONS
 AETIOPATHOGENESIS
 CLINICAL FEATURES
 TREATMENT
 COMPLICATIONS
 CARRY HOME MESSAGE

3. INTRODUCTION
 Hand is a compact actively functioning unit due to
its mechanical and sensory functions.
 It is one of the most developed structures in the
human evolution.
 Infection may be due to minor injuries or blood
bone.

4. ANATOMY OF HAND
 The hand is the region of the upper limb distal
to the wrist joint.
 It is subdivided into three parts:
 1. Wrist
 2.Metacarpus
 3.Digits (five fingers including the thumb).
 The hand has an anterior surface (palm) and
a dorsal surface (dorsum of hand).

6. Anatomy of Nail

7. CLASSIFICATION OF
INFECTIONS
 1. Spreading infections – spread to involve a large
area of the hand.
 Eg: cellulitis and Lymphangitis.
 2. Localized infections – localized to an area of the
hand because of the anatomical factors.
 On the dorsum of the hand:
 subcutaneous infection
 Infection deep to the aponeurosis.
 On the palmar aspect of the hand:
 Superficial aponeurotic infection
 Deep aponeurotic infection
 Thenar space infection
 Mid-palmar space infection.

8.  Others:
 Apical space of finger infection
 Terminal pulp space infection
 Middle volar space infection
 Proximal volar space infection
 Web space infection
 Tenosynovitis
 Space of parona’s infection

9. AETIOPATHOLOGY:
 Common in Manual workers & Housewives
(Traumatic).
 Immunocompromised states like Diabetes
Mellitus & HIV.
 Immunosuppression with Drugs like Steroids &
CancerChemotherapy
 Vascular Diseases.
 Most common organism: Staphylococcus aureus.
(80%).
 Other organisms like: Streptococcus; Gram
Negative Bacillus Like E.coli, Klebsiella,
Pseudomonas.

10.  The organisms reach the tissues planes by direct
implantation from outside or via the blood.
Swelling,
Erythema &
Tenderness
with
progression
to abscess
formation.
Spontaneous
decompression
can occur,
(subungual
abscess).
Deeper
infections
can involve
the nailbed,
pulp space,
and bone

11. GENERAL FEATURES:
 Infections spreads faster in all areas.
 Oedema develops – frog hand (oedema in
Dorusm of hand).
 Restricted movements of fingers and hand.
 Loss of hook, pinch, grip and grasp.
 Severe pain and tenderness with fever.
 Tender palpable axillary lymphnodes.

12. Acute Paronychium
 Infection of nail fold.
 It is the commonest infection of the hand.
 Results from careless nail paring or use of unsterile
manicure instruments.
 Clinical Features:
 Pain, Tenderness, Redness and Swelling at one
or both sides of the nail fold; and at base if
suppuration
extends till the base.
 Marked Tenderness on pressing the nail.

13. Clinical Presentation
Initial swelling,
erythema, tenderness
with progression to
fluctuance, and
abscess formation are
typical.
Spontaneous
decompression can
occur, including
tracking beneath the
nail plate (subungual
abscess).
Deeper infections can
involve the nailbed,
pulp space, and bone,
producing nailbed
destruction, felon, or
osteomyelitis

14. TREATMENT
 Early stage
 Oral antibiotics,
 Warm soaks
 Rest and observation
 Surgical decompression is the treatment of choice
 Decompression is performed by carefully entering the
abscess cavity between the nail plate and nail fold with
a scalpel blade .
 Asmall wick is placed for 24 to 48 hours to prevent the
incision from closing and recurrence of the infection. The
wick is removed, and saline warm soaks are begun.

15. • Depending on the extent of the
infection, a partial or complete
nail plate
removal with or without lateral nail
fold
relief incision(s) is performed.
• The incision should be made
perpendicular to the edge of the
nail
fold.
• Asingle or double incision is
used
depending on the location of the
infection.
• Subungual abscesses are treated
with
removal of a portion of or the

16. (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.

17.  Complications:
 Extension of infection into pulp space.
 Chronic Paronychium.
 Chronic paronychia
 Chronic paronychia occurs more commonly in
individuals constantly exposed to moist environments.
 Infections may be intermittent; clinically, the
eponichial fold is thickened and painful
 Candidaalbicansis a frequent offending organism
 Topical antifungal ointments are generally used 4 to 6
weeks.
 Marsupialization; nail removal if deformed.

18. Apical Subungual Infection
 Infection of the tissues between the nail plate and
the periosteum of the terminal phalynx.
 Results from a pin-prick or splinter beneath the
nail.
 Excruciating pain with little swelling.
 Tenderness is maximum beneath the free edge of
the nail.
 Pus comes to the surface at the free edge of the
nail.

19.  Treatment:
 In the early stage, conservative
management.
 For suppuration – drainage of pus.
 A small V-Shaped piece if
removed from the centre of the
free edge of the nail along with a
little wedge of the full thickness of
the skin overlying the abscess.
 Complications:
 Chronic sinus due to pus spread.
 Extension of infection into tip of
phalynx.

20. Terminal Pulp Space Infection
 Also known as “Whitlow” or “Felon”.
 SurgicalAnatomy: The terminal pulp space
is the volar space of the distal digit.
 Filled with compact fat, feebly partitioned
by multiple fibrous septae.
 At its proximal end, space closed by a
septum of deep fascia connecting the
distal flexor crease of the finger to the
periosteum just distal to the insertion
of the profundus flexor tendon.

21.  15-20 longitudonal septa anchoring
skin to distal phalanx dividing the pulp
into multiple closed compartments.

22.  Pathophysiology
 Infection typically is due to direct inoculation of bacteria by
penetrating trauma but may be caused by
 hematogenous spread
 local spread from an untreated paronychia.
 Most common in thumb and index finger.
 Clinical presentation
 Throbbing pain and
 Tense swelling localized to the pulp

23.  “Don’t wait for fluctuation if tension is severe”
 Infection results in edema  increased pressure within the closed
compartment impaired venous outflow  local compartment
syndrome.
 Untreated felons can:
 extend toward the phalanx --> osteomyelitis
 toward the skin --> draining sinus
 obliterate vessels ---> skin slough or necrosis
 suppurative flexor tenosynovitis or septic arthritis of the DIPJ

24. 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 nerve and vessel
structures
 Utilize an incision that won’t leave a
disabling scar
 Do not violate flexor sheath (stay
distal)

25. Complications
 Osteomyelitis of the terminal phalynx – with necrosis
and sequestration of distal half due to thrombo-
arteritis of digital vessels.
 Pyogenic arthritis of the distal interphalyngeal joint.
 Suppurative tenosynovitis of flexor tendon sheaths.

26. Web Space Infection
 Anatomy:
 A triangular space between the
bases of adjacent fingers.
 Clinical features:
 Infection arises from skin crack;
 From a purulent blister;
 Proximal volar space infection
through
the lumbrical canal.
 Oedema over back of the hand.
 Swelling at the base of the finger,
 Fingers are seperated from the
adjacent fingers.
 Tenderness maximum in web and

27. Treatment:
 In early stage – conservative treatment with
antibiotics.
 In late stages – incision and drainage.
 Transverse incision on palmar surface;
 With constant probing pus drained,
 Edges of the wound are cut away with a diamond
shaped opening.
 A conter incision given over dorsum of hand.
Complications:
 Infection spreads to adjacent spaces and
Tendon sheaths.

28. Deep Palmar Abscess
 A serious but rare infection.
 Infection in the thenar or mid-palmar space.
 Anatomy: Deep palmar spaces lie in the hollow of
the palm, deep to the flexor tendons and their
synovial sheaths.
 Space is divided into a medial mid-palmar space
and a lateral thenar space.
 Posterior relation is formed by fascia covering the
interossei and metacarpals on medial side &
adductor pollicis muscle on the lateral side.

30. Clinical Features:
 Infection arises from penetrating wound via blood
stream or complication of suppurative
tenosynovitis.
 Severe swelling on dorsum of hand – frog hand.
 Extension at MCP Joints very painful & painless
at IP Joints.
 Regional lymphadenopathy present.

31. Treatment:
 Needle aspiration to confirm pus.
 A central transverse incision in the line of flexor
crease.
 Through deep probing, pus to be drained and
skin edges & palmar fascia trimmed
Complications:
 Discharging sinus.
 Stiffness of the hand.

32. Acute Suppurative Tenosynovitis
 It’s a rare but important infection; prompt treatment
essential.
 Anatomy:
 Flexor sheaths are closed spaces
 Extend from the mid-palmar crease to
the DIPJ (Prox edge of A1 pulley to distal
edge of A5pulley).
 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).

33.  Flexor sheath infections most often as a result of penetrating trauma
 More likelyat 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
 Purulence within the sheath destroys the gliding mechanism,
rapidly creating adhesions that lead to loss of function
 Destroys the blood supply producing tendon necrosis.

34. 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 allfour signs may be present early on
 Most reliable sign: painw.passiveextension
 Cellulitis of the hand may appear similar,
but swelling &tenderness is not usually
isolated to a single digit

35.  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.
 Delay may result in skin/tendon necrosis.

36. Carry Home Messages:
 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.

37. Thank you