Hand Infections Overview Cellulitis Paronychia/eponychia Felon Herpetic Whitlow Flexor tenosynovitis Deep fascial space infections Septic arthritis Osteomyelitis 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 Treatment Immobilize Elevate Antibiotics – Keflex, Augmentin, Diclox Disposition D/c home with 24 h follow up unless… Immunocompromised Systemically ill Rapidly spreading Paronychia 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 Paronychia If extends to overlying proximal nail: eponychia S. aureus Thumb sucking/nail biting – anaerobes Chronic – candida Treatment Early Cellulitis Soaks, elevation, antibiotics (Keflex…) Paronychia 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 Paronychia Complication… Osteo of distal phalanx Refer to a hand surgeon.. Felon Infection of the pulp of the distal finger or thumb Septa Facilitate infection Inhibit drainage BUT Act as a barrier protecting the joint space and tendon sheath…limits proximal spread Felon 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 finger Felon Felon Treatment 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 Felon Complications 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 Vesicles Coalescence over 2 weeks Ulcer formation Hemorrhagic base May look like a felon but DRAINAGE IS CONTRAINDICATED!! 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 dressing 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 Treatment Splint and elevate Amp/Sulb or Cefazolin and a PCN Consider Vancomycin if IVDA Consider Ceftriaxone if concern of disseminated gonococcal infection ADMIT AND HAND CONSULT 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 anaerobes Deep Fascial Space Infections Dorsal subaponeurotic abcess Swelling and erythema on dorsum of hand Pain with passive movement of extensor tendons 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 Treatment Antibiotics to cover staph Hand consult for open drainage in OR Osteomyelitis Most common with open fractures or soft tissue infections Fever, redness, swelling, warmth, tenderness, pseudoparalysis (in kids) Plain film – bony destruction or periosteal elevation Treatment 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 Treatment Antibiotics to cover Strep, Staph, Anaerobes, Eikenella, Neisseria Amp/Sulb Clean and irrigate throroughly Leave open Immobilize Elevate Hand consult References Canale: Campbell’s Operative Orthopaedics, 10th ed. 2003 Mosby, p.3814 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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