Infections of Hand & Feet Dr. Murali. M.S; M.B.A.

Asso.Prof.of Surgery

HAND INFECTIONS

Introduction

•Hand is a compact actively functioning unit due to its mechanical & sensory functions.• It is one of the most developed structures in the human evolution. • Infection may be due to minor injuries or blood borne.

Spaces of the hand • Radial bursa • Ulnar bursa• Mid palm.space - space of

Parona• Thenar space • Dorsal subcutaneous space • Sup. pulp spaces of finger

Radial bursa

Space of Parona

Mid palmar space

Ulnar bursa

Thenar space

Tendon Zones – Modified Verdan Zone

• Zone 1 - One tendon only (FDP) from middle of middle phalanx distally• Zone 2 - Two tendons (FDS &

FDP) from MCP joints to middle of middle phalanx• Zone 3 - Central palm• Zone 4 - Tendons in the

carpal tunnel• Zone 5 - Tendons proximal to

the carpal tunnel

Precipitating Causes

•Diabetes• Immunosuppression• Trauma•HIV infection• Steroid therapy• Vascular diseases

Common Organisms

• Staph.aureus—commonest• Streptococcus•Gram–ve-E.coli,Kleb.,Pseud.•Occ. fungal infection & viral infection like orf can occur

General Features

• Infection spreads faster in all areas.• Causes oedema over the

dorsum of hand. It looks like frog hand.• Restricted movements of

fingers and hand. Hook, pinch, grip, grasp are lost.• Severe pain and tenderness,

with fever.• Tender palpable axillary lymph

nodes are often present.

Classification

[I] Cut.& sub-cut.infections:• Paronychia• Pulp Space Infection (Felon)• Web Space Abscess

[II] Fascial spaces infection :• Deep Space Infection i.e. midpalmar space, thenar space & Parona’s space.

• [III] Inf. of the tendon with its synovial sheath - “tenosynovitis”.

• [IV] Inf. of the bone & joint - “septic arthritis”.

• [V] Miscellaneous infections.

Investigations

• Pus for culture & sensitivity.

• Blood sugar.

• Urine sugar & ketone bodies.

• X-ray of the part.

General Principles • Position of rest & function

• Elevation of hand - ↓oedema

• Early recognition – I & D

• Blood less field

• After trt – Physiotherapy

Complications

• Stiffness of digits and hand (ankylosis)• Deformity and disability• Bacteraemia and septicaemia• Osteomyelitis of bones • Suppurative arthritis of joints• Paralysis of median nerve

1. Paronychia • Most common hand infection.• Infection of the soft tissues

surrounding the fingernail.• Minor injury - is the common

cause.• Severe throbbing pain and

tenderness with visible pus under the nail root. • The pus is drained by making an

incision over the Eponychium.

2. Felon • A felon is an abscess of the

distal pulp of the thumb or finger.• Usually a minor injury – finger

prick. • Infection results in edema and

increased pressure within the closed compartment. • Drainage of terminal pulp

space by an longitudinal deep incision.

3.Web space Abscess • There are 4 triangular web

spaces filled with fat between the dorsal and volar skin.• Begins beneath palmar callus –

in laborers.• Oedema of dorsum of hand +

Max. tenderness is on the volar aspect.• ‘V’ sign—Separation of fingers.• Incisions – 1 dorsal and 1 palmar.• Web - not incised

4.Deep space Infection • These are infections in the

potential deep spaces of the hand, i.e. Midpalmar space, Thenar space & Parona’s space. • Protects neuro-vascular

structures & permits gliding of tendons within the hand. • Infections - may follow blood

spread, penetrating injury or rupture of pus from a flexor tendon sheath.

4-a.Thenar space Infection • It lies post. to the long flexor

tendons to the index finger and in front of the adductor pollicis muscle.• Pain and swelling of thenar

eminence and first web space.• Thumb is held abducted &

flexed.• Combined dorsal and volar

incisions. Avoid injury to branches of median nerve.

4-b.Mid-palmar space Infection • It lies post. to the long flexor

tendons to the middle, ring and little fingers. It lies in front of the interossei and the 3rd,4th& 5th metacarpal bone. • Loss of normal hand concavity

with dorsal edema – “Frog’s hand”. Pain with movement of 3rd and 4th digits.• Either longitudinal or

transverse approach for drainage.

4-c.Parona space Infection • It is deep in the distal forearm

between the PQ muscle & the FDP tendons.

• This space is contiguous with the radial bursa, ulnar bursa and midpalmar space.

• A flexor tendon sheath infection may extend proximally to involve the bursae and Parona’s space.

• Swelling, tenderness, & occasionally fluctuance of the distal volar forearm. Digital flexion may be painful.

5.Dorsal space Infections • Diffuse swelling – Dorsum of hand

• Edema will be seen

• Normal concavity - palm

• Digital extension – very painful

• Treatment is similar to that

recomm. for other infections

6.Tenosynovitis • It is the bacterial inf. of flexor tendon

sheaths.

• It is the inflam. the fluid-filled sheath (called the synovium) that surrounds a tendon.

• Common flexor synovial sheath (ulnar bursa) [FDP / FDS]

• The synovial sheath of the tendon of flexor pollicis longus (radial bursa).

• Both comm. with each other in 80% of cases.

Tenosynovitis - contd “Kanavel Sign” – • Finger in slight flexion

• Fusiform swelling

• Severe pain on extension.

• Tenderness - tendon sheath

• Treatment is similar to that recomm. for tendon infections: open or closed irrigation, leaving a drain in situ and antibiotic cover.

FOOT INFECTIONS

Callosity

• It is a hard, thickened skin occurs as a protective measure seen in wider area usually over heel & heads of metatarsals.

• A callosity protrudes outwards from the skin.

Corn • It is localized area of

thickening over a bony projections like heads of metatarsals.

• It presses over the adjacent nerves causing pain.

• It can get infected causing severe pain and tenderness with inability to walk.

Ingrow Toe nail ( Onychocrytosis ) • It is due to curling of the side

of nail inwards, resulting in repeated irritation & infection of overhanging tissues in the nail fold.

• It is common in great toe and is often bilateral.

• Zadik’s or Fowler’s operation

Athlete’s Foot • It is the fungal infection of the skin

between the toes - Tinea pedis.• Fungi enter through cracks; survive

due to moisture in between toes.• Skin is swollen, red, with sticky fluid &

blisters. Itching, deep cracks, pain & discharge are common

• Part should be kept dry. Cotton, clean socks should be worn.

• Oral antifungals, antihistaminics and topical antifungals are used.

Key Points to RememberDo’s Don’tsExamine hand carefully Do not incise every infected digit

Think of other diagnosis Do not make puncture incisions

Wait for abscess to localize Do not injure digital vessels or nerves

Place adequate depth and length of incisions

Do not place incisions crossing the creases

Immobilize, elevate the hand Do not close bite wounds

Antibiotics & proper dressings Do not forget pus culture and sensitivity

References

Surgeon should have – “A heart of lion / Eyes of a hawk & Hands of a woman”.