Hand Infections Michael Fu February 26, 2014 Special thanks to Dr. Greg Difelice

Hand Infections

Michael FuFebruary 26, 2014

Special thanks to Dr. Greg Difelice

Hand Infections

– As a consequence of the complex anatomy and delicate functional balance of the hand, infections can be a source of considerable morbidity.

– Expeditious treatment is needed to minimize permanent dysfunction, loss of work and medical cost.

Routes of introduction

• Direct penetration• Spread from local compartments.• Hematogenous dissemination.

Routes of Dissemination

• Via anatomic compartments & fascial planes:• skin superficially

• subcutaneous tissue• fascia

• tendon sheaths• joints & synovium

• bone

Microbiology

• Most common organisms • Staphylococcus aureus (50%-80%)

• Streptococcal species• Gram Negatives

Patterns of Infection

• Work & Home acquired infections• single gram + species

• IV drugs / farm + soil injuries / bites / diabetics• mixed Gram +, Gram -, polymicrobial

• Chronic indolent infections• suggestive of atypical Mycobacterium or fungi

Patterns of Infection

• Human Bites• Alpha hemolytic Streptococcus

• Staph Aureus • Eikinella corrodens (33%)

• Domestic Cat & Dog Bites• Pasturella multocida

History

• Present with throbbing pain, swelling, redness, etc., Important to elicit a thorough history.

• Trauma - lacerations, bites, splinters, etc.,.

• PMH - DM, renal failure, immunocompromise, etc.,

• Occupation - medical care (H. simplex), gardeners (sporotrichosis), marine environment (M. marinum), animal farmers & meat handlers (Tularemia, Anthrax, Brucellosis), etc.,

• Other - IVDA, nail biting, distant infections, etc.,

Physical Exam

• Local - swelling (usually dorsal) , erythema, warmth, semi-flexed digits, intrinsic minus, pain w/ ROM, tenderness, fluctuance, drainage, etc.,

• Regional - lympangitis, adenopathy• Distant - febrile, distant foci

Dorsal Swelling / Intrinsic Minus

Radiographic Studies

– Xrays - foreign body, fracture, gas, advanced osteo

– Bone Scan - useful to screen for distant foci• sensitive, not specific

– MRI - excellent for early osteo - marrow edema• very sensitive, not specific• cost

General Treatment

• Rest, elevation, splint immobilization & early mobilization with OT.

• Empiric Abx coverage to start depending on likely organism. PO vs. IV.

• I&D if indicated.• Tetanus

Incision & Wound Management

• I & D - incisions, blood supply• I & D - no Esmarch, no epi

• Bulky Dressings • Splint in INTRINSIC PLUS position

• Wet to Dry, Wicks, Closure over drains/caths• Whirlpools & Soaks

• Occupational Therapy

General Splinting Position

• Wrist in extension• MCPs in flexion• IPs in extension• Thumb in palmar abduction

Specific Infections&

Treatments

Cellulitis

• Spreading, diffuse inflammation of skin & subQ. May involve deeper tissues.

• characterized by hyperemia, leukocytic infiltration & edema

• may be initiated by skin trauma, ulceration, dermatitis, lymphedema or nothing at all

• Most often Group A B hemolytic strep• Staph Aureus causes less extensive cellulitis

Cellulitis

• Diagnosis is primarily clinical.• Physical exam to r/o abscess or deep space

infection that is causing the cellulitis.• Little benefit in aspirating leading edge.• Rx- if mild may use oral abx- i.e. Keflex• If severe or no improvement w/ oral, then IV

abx- Ancef, Vanco if pcn allergy• Splint, frequent reassessments

Subcutaneous Abscess

• Local subcutaneous collection of purulence with surrounding erythema.

• Usually penetrating injury with fluctuant mass on PE.

• S. Aureus most common organism.• Aspirate for Gram stain & culture.• I&D, leave wound open, WTD/pack, splint.• Abx appropriate to clinical scenario.

Acute Paronychia

• Infection beneath the eponychial fold b/c of disruption in tight seal between nail & eponychial fold.

Pus beneath fold.

Acute Paronychia

• Most common hand infection• usually Staph Aureus• nail biting, manicures, poor nail

hygiene, hangnails, etc., predispose.

• May extend between nail & matrix.

• Treatment with Abx alone rarely effective.

• Usually require incision & drainage.

Acute Paronychia

• Sterile conditions, digital block w/ plain lido• Lift eponychial fold off of nail plate to

decompress• Place wick to maintain continued egress• If suspect abscess between nail & matrix, then

remove part of the nail.• Daily dressing changes +/- warm soaks

Chronic Paronychia

• Important to differentiate from acute paronychia.

• Intermittent cellulitis around the eponychium.

• Often recalcitrant to Rx.• Chronic separation leads to

Fungal, Gm -, etc., superinfect.• Rx- Full marsupialization &

removal of nail plate.• Abx +/- antifungals

Felon

• Closed space infections of the volar pulp space of the finger pad b/c of fibrous septae.

Felon

• Present with severe, throbbing pain & edema.• Etiology- penetrating injury to pulp• Staph Aureus most common organism.• Rx- if early ok to elevate, oral abx & warm soaks.

• Rx- Once fluctuance present it is critical to I&D to avoid pulp space necrosis, osteo and flexor tenosynovitis.

Felon

• I&D using digital block.• High lateral (B) & mid-

volar (A) incisions preferred.

• Avoid high lateral on ulnar side of thumb & radial side index for pinch.

• Pack open. Dressing changes & soaks.

Suppurative Flexor Tenosynovitis

• Prox. Margin of A1 to distal phalanx of I,L,R

• Thumb sheath contiguous with radial bursa.

• Small sheath contiguous with ulnar bursa

• Both radial & ulnar extend to carpal tunnel

• radial & ulnar bursae communicate in over 50% of individuals - can result in horseshoe infection.

Hand Infections


• Rapidly spreading bacterial infection within sheath as a result of penetrating trauma.

• Staph Aureus most common organism.• Chronic infection can result from

hematogenous spread of gonococcal infection.

• Chronic, often indolent, infections may be due to atypical mycobacterium.


• Kanavel’s Four Cardinal Signs• 1. Flexed posture of affected digit

• 2. Tenderness along flexor tendon sheath• 3. Diffuse, circumferential swelling of the digit• 4. Exquisite pain on passive extension from

the flexed position.

• One or all may be present. Key is early Dx.

Suppurative Flexor Tenosynovitis• Delay in treatment can cause tendon vascular

compromise and necrosis, resulting in adhesions and poor gliding.

• Differential diagnosis should include calcific tendonitis, flare of systemic arthropathy, Gout, etc.,


• In very early cases or if dx is ?able-- 24 hrs of IV Abx, splint & elevate. If no improvement then surgical treatment is necessary.

• Surgical treatment options include:• limited incision method utilizing irrigation cath• full open drainage- midaxial or volar incision

• Institute mobilization with OT early.

Patient 1- Suppurative Flexor Tenosynovitis

Hand Infections


Hand Infections


Hand Infections


Hand Infections

1 week follow-up 3 week follow-up


Hand Infections

Final Functional Result- Full Recovery

Patient 3- Suppurative Flexor Tenosynovitis w/Proximal Extension

Hand Infections

Patient 3- Suppurative Flexor Tenosynovitis w/Proximal Extension

Hand Infections

Human Bites• Typically clenched fist injuries from punch to mouth. • If not seen within 24 hours should assume infected.• May seem innocuous due to multiple planes of injury that

alter alignment in different hand positions.• Wound over MCP should be considered intrarticular until

proven otherwise to avoid potential consequences of untreated septic arthritis.

Patient- Bar Room Brawler

Hand Infections

Human Bites• Human saliva has demonstrated 42+ species.• Leaders- • Grp A Strep, S Aureus, E corrodens (30%)

• Bacteriodes most common anaerobe.• Rx-- surgical extension of wound & explore I&D

• Err on the side of caution with a low threshold to admit, splint, elevate, Broad Coverage IV Abx. Allow to heal by secondary intention.

• Especially with Diabetics & Immunocompromised

Animal Bites

• Dogs >> cats > rodents• Cat bites felt to be worse due to needle like

puncture• Pasteurella multocida (facultative anaerobe)

most common. Staph, Strep & anaerobes common.

• Rx- Careful irrigation of the wound and exploration if suspicion of deeper involvement. Oral prophylaxis at least for most wounds.

Animal Bites

• If infected then commonly require formal I&D, hospitalization and IV Abx.

• Empiric Abx coverage should be broad such as: 1st Gen Ceph, Unasyn or Augmentin

Patient- Cat Bite

Hand Infections

Patient- Cat Bite

Patient- Cat Bite

Patient- Cat Bite

Necrotizing Fasciitis

• LIFE & LIMB THREATENING EMERGENCY• Most commonly seen in IVDA population.• Single pathogen - grp A B hemolytic Strep or

polymicrobial w/A & B hem Strep, Staph & anaerobes.


• Present w/extreme pain, rapid advancement, cellulitis w/ poor margins, tense swollen skin. Ecchymosis & bullae appear w/ time followed by elevation in WBC.

• Inability to stabilize hemodynamic status in the face of superficial infection should raise suspicion.


• Rx is RAPID SURGICAL INTERVENTION• findings include liquefaction of fat & fibrinous necrotic tissue,

thrombosis of subQ vessels, foul smelling “dish water” pus. Muscle is often spared.

• Wide surgical debridement of involved tissue and skin imperative.

• Broad spectrum Abx coverage critical.• Poor prognostic factors- >50 yrs, chronic illness, DM, truncal

spread.• Most important factor to recovery is thorough debridement.

Patient- Necrotizing Fasciitis



Thank You

Documents

Hand Infections Michael Fu February 26, 2014 Special thanks to Dr. Greg Difelice