1. Dr. Tauseef ul Hassan

2. 
 approx 35% of patients admitted to hand surgery
services.
 Majority are result of minor trauma for which
treatment is delayed or neglected.
 Occasionally these are results of drainage efforts by
patients themselves under aseptic conditions.

4. 
 Uncomplicated Infections:
 Antiobitics alone will suffice.
 Evolved infections with localized collections:
 Antiboitics
 Drainage.

5. 
Any surgeon who accepts the responsibility for
drainage of a hand infection must undertake
comprehensive management responsibilities including:
 Preoperative Planning
 Surgical Approach
 Postoperative Care
 Rehabilitation.

6. A. Evaulation
B. Operative Principles
C. Rest/Heat/Elevation
D. Inpatient Care

7. A: EVALUATION

 HISTORY:
o Reveals the source of infection or predisposing factors.
o Previous injury to the site
o Bites --- Splinter --- Needle sticks --- surgical procedure
o Hand Dominance & Occupation
o exposure to certain pathogens.
o History of Systemic diseases like DM,
immunocompromised states.

8. 
 SYMPTOMS:
o Timing of events
o Pain
o Loss of function
o Drainage
o Fever
o Chills.

9. 
 Physical Examination:
o Exposure of whole extremity
o Signs of lymphangitis and lymphadenopathy
o A systemic approach to avoid missing critical
information.

10. 
 RADIOGRAPHS:
o Retained foreign bodies
o Rule out osteomyelitis
o Gas gangrene
o Serve as baseline for future comparison.

11. A. Evaulation
B. OPERATIVE PRINCIPLES
C. Rest/Heat/Elevation
D. Inpatient Care

12. B: OPERATIVE
PRINCIPLES

1. Incisions should never cross a flexion crease at a
right angle
2. Avoid iatrogenic injury to critical structures
1. Tendons
2. Neurovascular bundles
3. Incision lengthening is usually needed and should
be planned by making potential extensions with a
pen.

13. 
4. Torniquet Control is helpful as infective process
can lead to profuse bleeding.
o Finger Torniquet
o Penrose drain
o Glove technique
o Standard Pnematic Torniquet with exanguination
o Esmarch bandage
o Elevation of limb with digital pressure on brachial
artery.

14. A. Evaulation
B. Operative Principles
C. REST/HEAT/ELEVATION
D. Inpatient Care

15. C: REST – HEAT -
ELEVATION

a. REST (IMMOBILIZATION)
o Limits opening of tissue plans restricting the spread
of infection.
o Should be done in a functional position.

16. 
b. HEAT (WARM MOIST SOAKS):
o Maximum vasodilatory effect reached in 10 min.
o Frequent soaks preffered over continous soaks.
o Severe Infections:
o Moist hot towels with plastic barrier and a dry towel as
insulator.

17. 
c. ELEVATION:
o Reduces edema by improving venous/lymphatic
drainage.
o Limb should be above level of heart for dependant
drainage.
o Limb placed over chest or on a pillow while sitting.

18. A. Evaulation
B. Operative Principles
C. Rest/Heat/Elevation
D. INPATIENT CARE

19. D: INPATIENT CARE

 IV antiboitcs is the most common justification for
hospitalization.
 Continuous or intermittent wound irrigation.
 Frequent dressing changes.
 Three phases of treatment in cases of severe
infections where extensive debridement and
complex reconstructions are needed.

20. 
 Phase 1> Rapid infection contrtol and staged
debridement.
 A second look surgery done in 24-48 hours.
 Phase 2> Salvage of vital structures and soft tissue
coverage.
 With identification of structures that will later require
reconstruction.
 Phase 3 > Reconstructive Surgery.
 Once stable soft tissue coverage is achieved.

21. ANTIMICROBIAL
THERAPY

 Antiboitcs are indespensible adjuncts.
 Cultures should be obtained prior to antiboitics use.
 Most common pathogens involved are Staph aures
and Streptococcus sp.
 Usually gram +ve coverage is first choice.
 Consider MRSA while treating infections depending
upon patterns of resistance in a particular area.

22. ACUTE PROCESSES:

A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. Septic arthritis
I. Necrotizing Fascitits.

23. A. CELLULITIS

 Virtually all hand infections begin as cellutitis.
 Symptoms:
 Pain
 Swelling
 Erythema
 Lymphadenopathy
 Lymphangitis.

24. 
 Treatment:
 Oral antiboitics (usually gram +ve coverage)
 Rest
 Warm soaks
 Elevation.
 LYMPHANGITIS > Cellulitis accompained by
erythematous streaks up the arm.

25. ACUTE PROCESSES:

A. Cellulitis
B. PARONYCHIA
C. Felon
D. Palmer space infections
E. Pyogenci (Supparative) Flexor Tenosynovitis
F. Bite wounds
G. Septic arthritis
H. Necrotizing Fascitits.

26. B: PARONYCHIA

Infection of the soft tissues surrounding the
fingernail and is the most common infection of
hand.

27. 

28. 

29. 
 Cause:
 Inocculation of bacteria as a consequence of minor
trauma such as
 Nail bitiing
 Poor manicuring
 Small puncutre wounds.
 Staph aureus is most common pathogen but
anaerobes may also be involved.

30. 
 UNCOMPLICATED INFECTION:
 Oral antiboitics / Rest / Heat / Elevation
 INFECTION WITH ABCESS:
 Localized to one nail fold;
 Elevation of fold bluntly with a haemostat
 Using no 11 blade directing away from nail bed through
the insensate epithelium where abcess is pointing.

31. 
 Eponychia (involving proximal nail & one lateral fold;
 Elevating the eponychial fold and removal of loose
portion of nail plate to drain abscess and allow for
secondary healing.

32. ACUTE PROCESSES:

A. Cellulitis
B. Paronychia
C. FELON
D. Palmer space infections
E. Pyogenci (Supparative) Flexor Tenosynovitis
F. Bite wounds
G. Septic arthritis
H. Necrotizing Fascitits.

33. C: FELON

A felon is an abscess of the distal pulp of the
thumb or finger.

34. 

35. 
 Pulp Anatomy:
 15-20 longitudonal septa anchoring skin to distal
phalanx dividing the pulp into multiple closed
compartments.

36. 
 Pathophysiology:
 Abscess formation within these small compartments
results in rapid development of swelling and
throbbing pain, worsened by dependency.
 Complications:
 Necrosis of entire pulp
 Extension of infection into;
 Flexor tendon sheath
 Distal IP joint
 Distal phalanx.

37. 
 Causes:
 Mostly Puncture wound with foreign body, so radiographs
are mandatory.
 Pathogen:
 Staph aureus but gram –ve infection can also occur esp in
immunocompromised patients.
 Conservative Management: For early Felons…
 Oral antiboitics
 Rest
 Warm Soaks
 Elevation.

38. 
 Basic principles of Incision drainage;
 Avoid iatrogenci injury to neurovascualar structure
 Leave an acceptable scar
 Avoid flexor tendon sheath
 Drain all fluid collections adequately.
 Two types of INCSIONS:
 Volar Longitudonal incision
 Hockey stick or J- inscion

39. 

40. ACUTE PROCESSES:

A. Cellulitis
B. Paronychia
C. Felon
D. Herpetic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. Septic arthritis
I. Necrotizing Fascitits.

41. D: HERPETIC
WHITLOW

 Herpex simplex virus infection can be:
 Primary
 Recurrent
 Population at risk:
 Children, adolesents with genital herpes infection
 Health care workers with frequent exposure to oral
secretions.
 Must be distinguished from Paronychia and Felon
because incision and drainage is generally
contraindiacted.

42. 

43. 
 Pathophysiology:
 A prodromal phase of 24-72 hours of burning pain
prior to the development of skin changes.
 Erythema and swelling
 Formation of clear vesicles which sometimes coalsease
around nail fold.
 Fluid may become turbid but not frankly purulent
unless bacterial superinfection occurs.
 Pulp of affected digit is not tense as in felon.

44. 

45. 
 Disease Course:
 The process occurs over approx 2 weeks and resolves over
next 7-10 days.
 Diagnosis:
 Viral culture
 Tzanck smear
 Treatment: Generally conservative
 Rest & Elevation
 Anti inflammatory agents
 Acyclovir in immunocompromised states.
 Reccurence rates are around 20%.

46. ACUTE PROCESSES:

A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. PALMER SPACE INFECTIONS
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. Septic arthritis
I. Necrotizing Fascitits.

47. E: PALMER SPACE
INFECTIONS

 Thenar space
 Midpalmer space (subtendinous space)
 Hypothenar space
 Dorsal subapeneurotic space
 Web spaces.
 Thenar and midpalmer spaces are clinically more
important.

48. 
THENAR SPACE
INFECTION
MIDPALMER SPACE
INFECTION

49. 
 A penetrating injury usually a splinter is the most
common cause.
 Staph aureus is the usual pathogen.
 Antiboitics / Rest / Heat / Elevation for early
infections but most cases need Surgical Drainage.
 Key to success is adequate drainage while avoiding
iatrogenic injury and subsequent scar contracutres.

50. Midpalmer space infection
incisions and proceedures:

 Curved longitudonal incision in the palm.
 Take care to avoid injury to superficial palmer arch
and digital vessels.
 Wound packed open with daily dressing changes.
OR
 Irrigation catheter in proximal wound and a penrose
drain in distal wound for continous or intermittent
irrigation.

51. Thenar space infection
incision and procedure:

 Combined dorsal and volar incisions.
 Take care to avoid injury to palmer cutaneous
branch of median nerve in proximal end of incision
 And avoiding injury to motor branch of median
nerve.
 Post op care include
 Splinting
 Dressing changes
 Catheter irrigation.

52. 

53. ACUTE PROCESSES:

A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. PYOGENCI (SUPPARATIVE) FLEXOR TENOSYNOVITIS
G. Bite wounds
H. Septic arthritis
I. Necrotizing Fascitits.

54. F: PYOGENIC (SUPPARATIVE)
FLEXOR TENOSYNOVITIS:

 Most serious hand infection.
 If left untreated;
 Destruction of gliding
surfaces in sheath
 Necrosis of tendons
 Osteomyelitis
 Amputation.
 Ring, middle and index fingers mostly involved
 Staph aureus usual pathogen with few cases due to
haematogeneous spread of gonococcal infection.

55. 

56. 
 KANAVEL cardinal sign of flexor
tenosynovitis:
1. Fusiform swelling of finger
2. Paritally flexed posture of digit
3. Tenderness over entire flexor sheath
4. Dipropotionate pain on
passive extension.

57. 
 < 48 hours of onset of infection:
 IV antiboitics
 Rest / Heat / Elevation
 > 48 hours of onset of infection:
 Surgical drainage with zig zag brunner incisions
 Wound is packed open and loosely approximated
 Early and aggressive hand therapy initiated.
 Less severe cases:
 Catheter irrigation with limited incision .

58. ACUTE PROCESSES:

A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. BITE WOUNDS
H. Septic arthritis
I. Necrotizing Fascitits.

59. G: BITE WOUNDS

a) HUMAN BITES
b) ANIMAL BITES

60. a. Human bites:

 Potenitally serious due to high virulence of pathogens
invovlved.
 Common mechanism is clenched fist striking a
tooth, FIGHT BITE.
 Usually delayed presentation.
 Most commonly over the MCP joint, putting the extensor
mechanism and joint surface at risk.
 Radiographs are mandatory and may reveal;
 Tooth fragment
 Fracture of Metacarpel head
 Air in joint.

61. 
 All human bites in MCP joint region should be
explored;
 Joint space irrigated
 Edges debrided
 Primary wound closure never done.
 Closed after a week or 10 days
in severe cases
 Antiboitics / Rest / Heat / Elevation
 Usually covering gram +ve and anaerobes.

62. b. Animal bites:

Domestic Dogs and Cats
Tetnus status should be ensured.
Rabies prophylaxis
Thorough irrigation and exploaration of
joints when potentially voilated.

63. 
 Acute DOG bites;
 Sharpely debrided
 Loosely approximated
 Antiboitics / Rest / Heat / Elevation.
 Gram +ve and anaerobe coverage

64. 
 CAT bites can present late with closed space
abscesses due to trapping of bacteria inside wounds

65. 
 CAT scratch FEVER;
 Small pustule with surrounding edema at site of cat
bite
 Painful lymphadenopathy
 Symptomatic treatment
 Anti inflammatory
 Antiboitics
 Pain resovlves in 2 weeks but lymphadenopathy can
persist for months or years.

66. ACUTE PROCESSES:

A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. SEPTIC ARTHRITIS
I. Necrotizing Fascitits.

67. H: SEPTIC ARTHRITIS

 Destruction of articular surfaces.
 Mode of infection:
 Penetrating injury
 Local extension of adjacent infection
 Haematogenous spread (Gonococcal infection)
 Children;
 Streptococcus sp
 Staph aureus
 H. Infulenza
 Adults; with no history of trauma
 Suspect Gonococcus.

68. 
 Presentation; Septic joint will be
 Swollen
 Tender
 warm
 Marked pain on passive motion.
 Patient position of hand is to allow maximum joint
space;
 IP joints in 30 degree flexion
 MCP full extension

69. 
 Exploration is mandatory and joints are copiously
irragated and debrided.
 Joint packed open and dressing changes performed.
 Wound left to close by secondary intention.
 Antiboitics
 Rest / Heat / Elevation.

70. ACUTE PROCESSES:

A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. Septic arthritis
I. NECROTIZING FASCITITS.

71. I: NECTROTIZING
FASCITIS

 A life threatening, rapidly progressing infection of
the subcutaneous tissue and fascia.
 Diabetics and immunocompromised patients are at
greater risk.

72. 
Pathogenesis;
Low grade cellulitis  bullous changes in
skin cutaneous anesthesia with spread
into underlying subcutaneous tissuefat
necrosisvascular
thrombosiMyonecrosiscutaneous
vessel thrombosis.

73. 
 Mixed infection;
 Aerobes
 Anaerobes
 Clostridium sp result in gas formation in tissues with
crepitus on physical exam and air in tissues on
radiographs.
 Treatment:
 Repeated aggressive radical debridements
 Amputations above area of involvement
 Silvadene cream
 IV High dose antiboitics and tissue culture
 Hyperbaric O2.

74. CHRONIC
INFECTIONS:

A. CHRONIC PARONYCHIA
B. OSTEOMYELITIS
C. ONCHOMYCOSIS
D. VIRAL INFECTIONS
E. MYCOBACTERIAL INFECTIONS

75. A: CHORNIC
PARONYCHIA

 Presentation: Eponychium is;
 Indurated
 Erythamatous
 Occasional drainage from nail fold.
 Population at risk;
 Diabetics
 Frequent occupational exposure to moist conditions
 CANDIDA ALBICANS is the most common
pathogen.

76. 
 Medical Management:
 Topical antifungal
 Topical steroids
 Removal of thickened, deformed nail plate.
 Surgical Management:
 Eponychial Marsupalization.

77. CHRONIC
INFECTIONS:

A. CHRONIC PARONYCHIA
B. OSTEOMYELITIS
C. ONCHOMYCOSIS
D. VIRAL INFECTIONS
E. MYCOBACTERIAL INFECTIONS

78. B: OSTEOMYELITIS

 Mode of infection:
 Direct extension from an adjacent infection
 Septic arthritis
 Flexor tenosynovitis
 After open fracture
 Haematogenous seeding.
 Causative Bacteria:
 Staph aureus
 Hemophilus sp in young children.

79. 
 Presentation:
 Chronically draining wound
 Erythema
 Pain
 Swelling along the course of bone.
 Diagnosis:
 Radiographs
 Bone scans
 CT / MRI
 Bone culture and bone biopsy (Gold standard)
 Swab cultures

80. 
 Treatment:
 Long term antiboitic use for 4-6 weeks even upto 6
months.
 Spectrum kept broad at first, then narrowed based on
bone culture sensitivities.
 Bone curettage during biopsy taking.
 40% cases still need amputation.

81. CHRONIC
INFECTIONS:

A. CHRONIC PARONYCHIA
B. OSTEOMYELITIS
C. ONCHOMYCOSIS
D. VIRAL INFECTIONS
E. MYCOBACTERIAL INFECTIONS

82. C: ONCHOMYCOSIS
(TENIA UNGUIUM)

 Infected nails appear thickened and discolored
 Nail eventually separates from nail bed.
 Nail appear flaky.
 Causes:
 Trichophyton rubrum most common
 Candida albicans usually in diabetics.
 Fungal cultures always obtained prior to antifungal
therapy.

83. 
 Trichophyton rubrum responds best to oral
Terbinafine.
 Candida can be treated with;
 Topical nystatin
 Miconazole
 Oral ketoconazole
 Itraconazole
 Griseofulvin.
 Removal of nail plate may imporve
response for extensively involved nails.

84. CHRONIC
INFECTIONS:

A. CHRONIC PARONYCHIA
B. OSTEOMYELITIS
C. ONCHOMYCOSIS
D. VIRAL INFECTIONS
E. MYCOBACTERIAL INFECTIONS

85. D: VIRAL INFECTIONS

 Warts are viral infections caused by Human Papilloma
Virus (HPV).
 Types of warts;
1. Verruca vulgaris
 95%
 Rough
 Raised cauliflowerlike appearance.
2. Verruca plana
 5%
 Smooth
 Minimally elevated.

86. 
 Treatment options;
1. Keratolytic
 70% success rate
 Duration several days to several weeks
 Salicylic acid preparations
2. Cryotherapy
 Liquid nitrogen
 Without anesthesia
 Warts refractory to conservative management.

87. 
4. Surgical exicision
 Excised with atleast 1mm margin.
5. Laser ablation.
6. Electrocautery
7. Intralesional bleomycin or 5-flourouracil

88. CHRONIC
INFECTIONS:

A. CHRONIC PARONYCHIA
B. OSTEOMYELITIS
C. ONCHOMYCOSIS
D. VIRAL INFECTIONS
E. MYCOBACTERIAL INFECTIONS

89. E: MYCOBACTERIAL
INFECTIONS

 Typically uncommon
 Typical (Tuberculosis) Mycobacterial Infections
 Atypical Mycobacterial Infections.
MYCOBACTERIUM
MARINUM