Hand Infections by hilen

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									Hand Infections

 Cellulitis
 Paronychia/eponychia

 Felon

 Herpetic Whitlow

 Flexor tenosynovitis
Deep fascial space infections
Septic arthritis
Fight Bites
Cellulitis of the hand
Involves only the skin – erythema, edema, pain of
localized area
MUST document that deeper structures are not
involved- beware the dorsal hand cellulitis!
   Full painless ROM of digits, hand, wrist
   No tenderness on palpation of deeper structures
Strep pyogenes
   Occasionally S. aureus
Cellulitis of the Hand
 Immobilize
 Elevate
 Antibiotics – Keflex, Augmentin, Diclox

   D/c home with 24 h follow up unless…
      Immunocompromised
      Systemically ill
      Rapidly spreading
Localized superficial infection or abcess of
the lateral nail fold
Most common infection in the hand
Caused by frequent trauma to area
Swelling and tenderness of the soft tissue
next to the nail fold
May have associated cellulitis
If extends to overlying proximal nail:
S. aureus
 Thumb sucking/nail biting – anaerobes
 Chronic – candida

   Early Cellulitis
        Soaks, elevation, antibiotics (Keflex…)
Fluctuant – all of the above, plus…
   Drain
      May need anesthesia (digital block)
      Soften by soaking
      11 blade
      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
   Osteo of distal phalanx
        Refer to a hand surgeon..
Infection of the pulp of the distal finger or
 Facilitate infection
 Inhibit drainage
        BUT
   Act as a barrier protecting the joint space and
    tendon sheath…limits proximal spread
Caused by penetrating trauma and
secondary infection
S. aureus
Area of cellulitis and inflammation rapidly
progresses to severe throbbing, pain,
redness, swelling, tense feeling of distal
   Early and complete incision through septa
   Digital block
   Most drained by single lateral incision with blunt
    dissection, also volar approach
   Send cultures
   Irrigate, dress, elevate
   Reevaluate in 24-48 hours
   Antibiotics – anti-staph for 7-10 days
 Osteo
 Necrosis of palmar surface and formation of
  sinus tract
 Septic arthritis

 Flexor tenosynovitis
Herpetic Whitlow
HSV infection of distal finger
Either type
Most common viral infection of the hand
Caused by direct inoculation through
broken skin
 Kids with herpetic gingivostomatitis
 Adults more likely HSV 2
 Health care workers
  Herpetic Whitlow
 Single finger
 Pain, pruritis swelling
 Coalescence over 2 weeks
 Ulcer formation
 Hemorrhagic base
May look like a felon but DRAINAGE IS
Herpetic Whitlow
Herpetic Whitlow
Take a careful history…
Tender distal finger but SOFT pulp space
Clinical diagnosis
Resolves spontaneously in 3-4 weeks
   Prevent oral inoculation by covering with a dry
Acyclovir only if immunocompromised or
frequent infections
Flexor tenosynovitis
This is a surgical emergency – act quickly
to preserve function of digit and hand
Usually involves flexor tendon sheaths and
radial and ulnar bursae
Flexor tenosynovitis
Flexor tenosynovitis
Infection spreads along course of flexor
tendon sheaths, may spread to midpalmar,
thenar, lumbrical compartments
Caused by penetrating trauma to sheath
Consider disseminated GC if no trauma,
sexually active
S. aureus
   Also strep, anerobes, gram neg
Flexor Tenosynovitis
Clinical features
 Tenderness along course of tendon
 Symmetric swelling of the finger

 Pain on passive extension

 Flexed posture of finger
Flexor Tenosynovitis
 Splint and elevate
 Amp/Sulb or Cefazolin and a PCN

 Consider Vancomycin if IVDA

 Consider Ceftriaxone if concern of
  disseminated gonococcal infection
Deep fascial space infection
Palm is relatively fixed…the dorsum will
show the infection
Beware the dorsal hand cellulitis!
4 potential spaces
 Dorsal subaponeurotic space
 Subfacial web space
 Thenar space
 Midpalmar space
Deep fascial spaces
Deep fascial space infection
Infection from
 Direct penetrating trauma
 Contiguous spread

 Hematogenous spread

S. aureus, strep, occ. coliforms and
Deep Fascial Space Infections
Dorsal subaponeurotic abcess
 Swelling and erythema on dorsum of hand
 Pain with passive movement of extensor
 Looks like cellulitis

Subfacial web space infection
 Secondary to infection of palmar blisters
 Spreads dorsally - “collar button abcess”
Collar Button Abcess
Deep Fascial Space Infection
Thenar space infection
 Pain and swelling of thenar eminence and first
  web space
 Can be from tenosynovitis of 2nd digit with
  rupture proximally
 Thumb is held abducted and flexed
Deep fascial space infection
Midpalmar infection
 Loss of normal hand concavity
 Tenderness of central palm
 Pain with movement of 3rd and 4th digits
 Can be from tenosynovitis of digits 3,4,5

Treatment for all
 IV antibiotics – Amp/Sulb
 Hand consult for open exploration and drainage
Septic Arthritis
Any joint
From direct inoculation from penetrating
trauma or contiguous spread
S. aureus (rarely others)
Nontraumatic? Think GC.
Joint is red, swollen, tender, localized
(unlike flexor tenosynovitis)
May have overlying puncture wound
Septic Arthritis
Held in position to maximize joint volume
Very painful passive flexion, axial load
Diagnose by arthrocentesis
 Antibiotics to cover staph
 Hand consult for open drainage in OR
Most common with open fractures or soft tissue
Fever, redness, swelling, warmth, tenderness,
pseudoparalysis (in kids)
Plain film – bony destruction or periosteal
   Antibiotics (long term)
   Debridement
Fight Bites
Incisor + oral flora + many tissue layers =
rapidly spreading infection
Physical exam – puncture wound, area of
cellulitis surrounding. Tendon maybe
visible inside the wound.
Plain film is indicated – often associated
with fractures
Fight Bites
   Antibiotics to cover Strep, Staph, Anaerobes,
    Eikenella, Neisseria
        Amp/Sulb
 Clean and irrigate throroughly
 Leave open
 Immobilize
 Elevate
 Hand consult
Canale: Campbell’s Operative Orthopaedics, 10th ed. 2003 Mosby,
Habif: Clinical Dermatology, 3rd ed. 1996 Mosby, p.343
Marx: Rosen’s Emergency Medicine: Concepts in Clinical Practice,
5th ed, 2002. Mosby, pp.529-532
Tintinalli: Emergency Medicine – a comprehensive study guide, 2000,
McGraw pp.1885-1890.

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