Hand Infections by BATIN 2006

Hand Infections Batin/Shum 2006 1 Overview            Intro Workup/ General Tx Felons Paronychial/ Eponychial infections Herpetic Whitlow Palmar space infections FTS Web space infections Necrotizing Fasciitis Bites Diabetic Infections 2 Introduction  30% of musculoskeletal infections  >10% infection rate with open hand fx Expeditious/appropriate tx < morbidity Delays lead to complications 3 Work-up  H&P Hx of diabetes? Rhuematologic/gout/metastatic dz? Immunocompromised? Possible foreign body? 4 Work-up  Radiographs Foreign bodies Gas in tissue Calcification in jt/tissue Bony changes:  Fx  Osteomyelitis  Gout 5 Work-up  Wound discharge Viral= “watery” Bacterial= “creamy” Fungal= “cottage cheese”  Cultures Obtain prior to Abx tx 6 Treatment  Labs Aerobe, anerobe Gram stain Fungus Atypical mycobacteria? Ziehl-Neelsen staining Lowenstein-Jensen 30° medium for cx Herpes simplex virus Tzanck smear 7 Treatment  Organisms Most common bugs  Staph a., Strep., gram negative species  Staph: 50-80% infections Industrial/home: gram positive IVDU/bites/farm/DM: polymicrobial  Gram negative  1/3 Human bites: Eikenella corrodens  Animal bites/scratch: Pasteurella multocida Immunocrompromised M. avium intracellare, TB, Crypto., Histo, Aspergillosis Indolent/chronic infection  Fungi or atypical mycobacterium 8 Treatment  Antibiotics Empiric coverage: aerobes/anerobes Cefazolin and PCN IVDU/DM: add aminoglycoside  Gentamycin  SE: nephrotoxicity and ototoxicity MRSA Vancomycin: 3 case reports of VRSA in US Clindamycin for CA-MRSA: D-test TMP-SMX, rifampin, cipro Herpes: consider Acyclovir 9 Treatment  coverage until bug found vs. nothing most will need I&D, Abx, Splint  2-3d IV abx, 7-10d PO abx  Incisions Don’t cross Flex Crease at 90° Straight incisions Less flap necrosis NO BRUNNER incisions Allow easy extension 10 Treatment  Surgical management Adequate initial I & D Leave wound open Severe contamination Close by secondary intension Primary closure over drain Eventual graft or flap 11 Treatment  Post-Op Examine at 24/48 h Wet to dry to encourage granulation Soaks to encourage drainage OT ASAP 12 Cellulitis  Hyperemia, edema, lymphangitis What lies beneath? Skin and subQ but can be deeper  Offending Agent Group A, B-heme Streptococccus  Early cellulitis: PO abx for 24/49h Pcn V or cephalexin is best to cover both sta/str  IV abx Pcn V or cefazolin: Vanco for PCN/cefz allergies Skyhook in hospital 13 Subcutanous Abcess  Puncture  Staph aureus!  Expeditious I & D  Leave wound open 14 Paronychia Infections  Most common acute UE infection  Etiology Hangnail, fingernail biting, minor trauma, manicures ,  Begins beneath eponychial fold “runaround abcess” Proximal ext. can go between nail and matrix  #1 cause STAPH 15 Paronychium and Eponychium Paronychiae Eponychium 16 Paronychia Infection  Early tx Warm soaks Oral antibiotics (cover Staph) Surgical tx I&D Digital block Lift nail fold off of plate Hold open with gauze Partial nail excision Pus under nail plate 17 Paronychia and Eponychia Infection 18 Paronychia Infection Chronic Intermittent inflammation d/t constant moisture Eventual nail fold separation from plate Cheesy drainage?  Candida albicans  Tx: tolnaftate or clotrimazole Tx: marsupialization or complete nail removal with topical steroid/antifungal 19 Herpetic Whitlow  Superficial Herpes 1 & 2 viral infection  Higher risk in med & dent personnel Pre-school age children  Initial Sx = pain 2-14d after exposure  Vessicles that coalese, unroof, ulcerate lymphadenopathy, lymphangitis, fever  Self-limiting, resolving over 7-10d  Risk of infection until re-epitheliazation (2 wks)  Recurances asso. with stress/sun 20 Herpetic Whitlow  Vesicular lesions: clear fluid may become turbid resembling pus local erythema and tenderness  DON’T I & D: risk for superinfection! 21 Felons  SubQ infection  Penetrating injury  STAPH  Pulp anatomy  Fibrous septae for structural support  Vascularity to phalanx  Severe pain, tenderness, swelling  Sloughing/necrosis if no tx  Osteo can develop  Early tx  Elevation, soaks, PO abx  Abcess declaration 22 Felons  Surgical drainage: incisions Vertical midline incision Good for distal volar abscess Avoids digital nerves Minimal scar Don’t go to distal! Lateral incision deep abscess <3mm from nail border MUST break across septae 23 Felons 24 Felons  Check for osteo intraop  Avoid “fishmouth” incisions  Pack wound open for 24-48hrs  Daily soaks 25 Pyogenic Flexor Tenosynovitis  Bacterial infection of tendon sheath  Usually due to penetrating trauma Hemotogenous spread: gonococcus STAPH, don’t forget about gram negs or atyps Tuberculosis in the immunocompromised!!!  Untreated can lead to tendon necrosis  Requires prompt surgical drainage 26 Bursae anatomy Ulnar Bursa Radial Bursa 27 FTS  4 Kanaval signs (1939) 1) Flexed resting position of digit 2) TTP along flexor sheath 3) “Sausage” finger (fusiform swelling) 4) severe pain with passive extension Early: all signs may not be present Delay in tx: tendon vascular compromise Necrosis Adhesions 28 FTS 29 FTS  Horseshoe abcess  Parona’s space PQ below, FDP, FPL above  Thenar space infection 30 FTS treatment  Early (w/in 24h) Elevation, splint, IV abx for 24h  I & D and irrigation catheter More rapid rehab and recovery  Splint, irrigate 50cc NS q2hr  Catheter and wet dressing pulled at 48 hrs  Wet to dry, soaks, early ROM  Requires compliant pt, good ancillary staff 31 FTS irrigation 32 Ulnar bursa irrigation 33 Deep Space Infections     Direct penetrating wounds 1) Dorsal subaponeurotic space 2) Interdigital subfascial web spaces 3) 3 potential spaces  Thenar space  Deep to thenar musculature  Sign: Thumb forced into abduction  Mid-palmar space  Between fascial band from 3rd MC & hypothenar septum  Hypothenar space  Superficial to hypothenar musculature  Infections require drainage  Dorsal swelling may be only sign 34 Palmar Space Infections: Anatomy Hypothenar space Midpalmar space Thenar space 35 Palmar Space Infections: Anatomy 36 Deep space infections  1)Dorsal subaponeurotic space Longitudinal incision along 2nd MC and btwn 4th/5th  2)Thenar space Penetration or index finger extension  dorsal web space  between adductor pollicis and first dorsal IO (“pantaloon”) Sign: thumb abducted thenar crease incision Avoid recurrent branch Median N. Possible 1st dorsal web space incision 37 Thenar Incision  To ensure adaquate drainage Use two-incision 38 Deep space infections  3)Midpalmar Space Loose palmar concavity: looks flat Painful MF/RF motion Incision just prox to distal palmar crease NV dangers just below skin… Superficial palmar arch Radial artery (37% ulnar a) Dissect ulnarward 39 Midpalmar Incisions 40 Deep space infections  4)Hypothenar Space Incision radial aspect of hypothenar eminance More superficial than other 2 spaces Very rare  5)Web Space: “Collar-Button” subfacial palmar to dorsal extension Dumbell shaped Two-incisions 41 Collar Button Abscess incisions 42 Human Bites  Clenched fist: “fight bite”  wound over MC head, but proximal when hand extended  Bite induced  Offending agents: aerobes and anerobes  Strep, Staph, E. corrodens  Tx for bone and joint involvement Explore, irrigate debride, admit, elevate, IV abx Better results with I&D AND IV abx  PCN G, 2nd gen cephlasporin No difference in IV vs PO abx post debridment Heal by secondary intension Delayed tendon repair 43 Animal Bites  Dogs>cats>rodents  15-20% dog bites infected  50% of cat bites infected  Usually combo of aerobe & anaerobe  Cats AND dogs  Pasturella multocida  PCN or cephalosporin sensitive  Don’t close any bites  Rabies  No tx if healthy animal; observe 10 days  Skunk, bat, fox, coyote, raccoon, bobcat  Human diploid cell vaccine  Rabies immune globulin  Hamsters, rabbits, mice, rats, squirrels  Almost never tx needed 44 Necrotizing Fasciitis  Life and limb threatening infection  Etiology: Minor/blunt trauma  Risks: IVDA, DM, age>50, HTN, obesity  Painful rapid spread along fascial planes Cellulitis, swollen, shiny skin Bullae and eccymosis Most are mixed infections  CT scan →subfascial gas  Dx→“dishwater pus”, necrotic tissue, fat liquifaction  Most are mixed infections B hemolytic strep, group A strep staph, anaerobes 45 Necrotizing Fasciitis a.k.a “flesh eating bacteria” 46 Necrotizing Fasciitis -liquifaction necrosis of sub-Q fat -air tracking along deep fascial planes -vascular thrombosis causes skin changes (blue-grey patches) 47 Necrotizing Fasciitis -skin ulceration -muscle involvement -infection extends along fascia beyond affected skin (“undermining”) 48 Necrotizing Fasciitis       Emergent and aggressive debridement to normal fascia Keep wounds open & moist Re-exam & re-debride Broad Spectrum ABX Hyperbaric O2 for anaerobe infections HIGH MORBITY  33% 49 Mycobacterial Infections  M. marinum Most common Indolent infection  Contaminated pools, marinas  fish tanks/bites/fins/spines 30° Lowenstein-Jensen cx Tx: 4-6 months  Cutaneous; self limited  Subcutaneous: I&D w/ 2-6 mo abx  Deep: syno/tenosynovectomy, I&D, 4-24 abx Abx: Minocycline→ ethambutol and rifampin  M. avium intracellare #1 in terminal AIDs Soil, water, poultry 50 Fungal Infection  Sporotrichosis Most common in NA; dx often missed! Rose thorns, cactus, sphagnum moss Ulceration at puncture site with nodules up lymph vessels—can ulcerate! Isolation of S. schenckii Tx Then: K+ Iodide Now: oral iatroconazol Deep: I and D 51 Were you paying attention? 52 50yo IDDM with increasing pain over the palm. Exam reveals TTP over the radial side of the pam and pain on attempts to flex the thumb and index finger. The thumb is in a slightly abducted position. Dx is most likely… 1. 2. 3. 4. 5. midpalmar space infection. thenar compartment syndrome. thenar space infection. FTS of the FPL. FTS of the index flexor. 53 54  32 yo respiratory thereapit has pain and swelling in the pulp of his ring finger. Exam reveal swelling, eryethema of the pulp, and multiple 1 and 2mm vessicles. Management should consist of… 1. oral PCN. 2. IV cephlasporin. 3. I and D of pulp. 4. observation 55 51 yo fisherman presents with a firm indurated mass overlying the distal metacarpals of the long and ring fingers. The next step in management consists of… 1. I & D, skyhook, and IV abx. 2. PO abx and soaks. 3. biopsy and cx on chocalate agar at incubated at 35° C. 4. biopsy and cx on Lowenstein-Jensen medium at incubated at 30° C. 56 A purulent FTS of the small finger may communicate with the thumb flexor via the… 1. 2. 3. 4. thenar space. hypothenar space. carpal tunnel. Parona’s space. 57 Another toddler has bit Dylan’s hand and the wound has been cultured positive for Eikenella corrodens. The preferred antibiotic is… 1. 2. 3. 4. clindamycin. iatroconozole. minocycline. penicillin. 58 The End 59