HAND
INFECTIONS
by Mr Gauthamen
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Hand
Infection
Nail bed
Infection
Herpetic
Whitlow
Flexor
Tenosynovitis
Deep
Space
Infections
Cellulitis &
Lymphangitis
Animal/
Human bites

Focus of Discussion
1. Nail Bed Infection
• Acute Paronychia
• Chronic Paronychia
• Subungal Abscess
• Felon
2. Flexor Tenosynovitis
3. Deep Space Infection
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Nail Bed Infections
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Anatomy of Nail Complex
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Acute paronychia
• Infection of the nail fold
• Most common infection in the hand
• S. aureus most common infecting organism
• Common cause:
• Hang nail
• Nail Biting/ Sucking
• Manicures
• Penetrating trauma
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EARLY STAGE ABSCESS FORMATION “RUNAROUND INFECTION”
• Topical Antibiotics
• Oral Antibiotics
• Surgical ( I&D)
• Antibiotics
• Surgical ( I&D)
• Antibiotics

Operative methods
• Direct incision away from nail bed (B)
• Extend incision proximally as
necessary
• If eponychium is involved, make
another parallel incision along
opposite nail fold, elevate the
eponychium and reflect it above nail
plate (C & D)
• Infection below nail plate – remove
the nail plate partially/totally.
• Purulence below nail plate -> ischaemia
of germinal matrix
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Postop Care
• 7-10 days antibiotic
• Daily soaks in normal saline 5, 2-3 times/day
• Early ROM exercises
• Discontinue packing/wicking at 3-4 days
• Expect tenderness/hypersensitivity around surgical scars lasting
several months
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OSTEOMYELITIS SUBUNGAL ABSCESS

Chronic Paronychia
• Distinct clinical problem from acute
paronychia
• Multifactorial inflammatory reaction of
the proximal nail fold to irritants and
allergens
• Characterized by chronically indurated
and rounded eponychium, may results in
thickening and grooving of the nail plate
• Middle-aged women
• Female : male = 4:1
• Frequent immersion in detergents
• Gram +ve cocci, Gram –ve rods, Candida,
mycobacterial sp.
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Nail plate
hypertrophy
Nail fold
blunting and
retraction
Transverse
ridges on
nail plate

Pathophysiology
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Separation between nail
plate and dorsal soft
tissue
Colonisation usually by
Staph
Subsequent infection by
Candida albicans and/or
colonic organisms
Chronic inflammation
with recurrent
exacerbations –
increased erythema and
drainage
Reduced resistance to
minor bacterial insults
Fibrosis and
thickening of
eponychium
Decrease in
vascularity to
dorsal nail fold
Recurrent
episodes of
exacerbations

Treatment
• Conservative
• Reduce exposure to irritants
• Topical steroids
• Oral + topical antibiotics and antifungal
• Operative
• Eponychial marsupialisation
• Most common surgical treatment
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• Crescent-shaped incision 1 mm proximal to distal edge of eponychial
fold extending 3-5 mm proximally.
• Remove crescent tissue down to but not including germinal matrix
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Postop Care
• Postop dressing removed at 48-72 H
• Soak in normal saline solution 3 times/day
• Continue until 2 days after all drainage has stopped
• Oral antibiotics for 2 weeks
• Wound healing by secondary intention by 3-4 weeks
• Scar sensitivity and nail deformity more common than in acute
paronychia
• Correct environmental factors, systemic comorbidities to avoid
recurrence
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Felon
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Felon
• Subcutaneous abscess of distal pulp of
finger/thumb
• Involve multiple septal compartments
• 15-20% of all hand infections
• S. aureus
• Gram –ve oraganisms in
immunocompromised
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Clinical presentation
• Severe throbbing pain, tension and swelling of entire distal
phalangeal pulp
• Does not extend proximal to DIPJ flexion crease, unless the joint or
tendon sheath is involved
• History of penetrating injury
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Treatment
• Nonsurgical only in very early presentation
• Surgical drainage in tense pulp even without abscess
• Aim:
• Avoid injury to digital nerve and vessels
• Non-disabling scar
• Preserve function of finger pupl
• Fine tactile sensibility
• Maintain stable, durable pad for pinch
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Surgical Drainage
• Incision
• Place incision opposite the pinching surface or at the side of maximal
tenderness
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Post op care
• Keep wound open for 2-5 days
• Place a gauze wick in the wound up till 3-5 days
• Soak in dilute povidone-iodine 3 times/day
• Allow wound healing by secondary intention
• Early finger ROM
• Expect recovery in 3-4 weeks
• Expect tenderness and hypersensitivity lasting several months
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Pyogenic Flexor Tenosynovitis
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Pyogenic Flexor Tenosynovitis
• Closed-space infection of the flexor
tendon sheath of the fingers or thumb
• Destroys tendon gliding mechanism
• Creates adhesions
• Lead to tendon necrosis
• S. aureus and β-hemolytic
Streptococcus
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HORSE SHOE ABSCESS

Clinical Presentation
• The 4 Kanavel signs
• Excruciating pain along tendon sheath on passive extension
• Semiflexed finger position
• Fusiform swelling
• Excessive tenderness limited to course of flexor tendon sheath
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Treatment
• Nonsurgical
• No role
• Orthopaedic Emergency!
• Refer to Orthopaedic
• Surgical
1. Open tendon sheath irrigation method
2. Through-and-through intermittent antibiotic irrigation
3. Closed tendon sheath irrigation
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Operative Treatment
• 2 principal approaches
• Midlateral
• Brunner
• Multiple variations
• Nevaiser – 2 hourly NS
flush for 48 H +/- another
24 H
Intraop
• Irrigate till clear fluid
seen distally
• Debride any wounds
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Postop care
• Elevate the hand
• IV antibiotic 7-10 days followed by oral to complete a 4-week course
• Early ROM with therapist supervision
• Return to OT no improvement in first 24-36 H
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Risk factors for poor prognosis
• DM
• Late presentation
• Human bite
• Age >43 years
• Renal failure
• PVD
• Subcutaneous purulence
• Polymicrobial infection
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• Diabetes (39% amputation rate)
• Peripheral Vascular Disease (71% amputation rate)
• Renal Failure (64% amputation rate)
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Deep Space Infections
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Deep space infections
• Anatomical Spaces in hand
1. Thenar space
2. Hypothenar space
3. Midpalmar space
4. Dorsal subaponeurotic space
5. Web space
6. Dorsal Adductor space
• Dorsal to the adductor pollicis and palmar
to the 1st dorsal interosseous
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Clinical presentation
• Penetrating trauma
• Thenar and midpalmar space infections can happen from spread of
pyogenic flexor tenosynovitis
• Thenar space – most common deep space infections
• Midpalmar – rare
• Hypothenar – extremely rare, not in continuity with any flexor tendon
sheaths
• All will have exquisite tenderness over the involved palmar space
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Thenar space
• Swelling of thenar
eminence/entire
hand
• Thumb abducted
• Pain with passive
adduction
Midpalmar space
• Dorsal swelling
predominates
• Loss of palmar
concavity
• Flexed posture of
MF, RF
• Pain with passive
extension of fingers
Hypothenar space
• Localised
tenderness and
swelling of
hypothenar
eminence
• No palmar swelling
• No finger
involvement
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Web space
infection
• Swelling and tenderness
over the web space
• Finger position in “V”
shape
• Known as Collar Button
Abscess if it extend
dorsally

Treatment
• No role of nonsurgical management
• Refer Orthopaedics
• Incision and drainage
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Thenar Space Drainage
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Midpalmar Space Drainage
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• Take home message:
1. Holistic approach during health check-up
• Inspect the hand / foot
• Reinforce Diabetic control
2. Treat hand infections as Orthopaedic
Emergency when significant evidence of
infection / collection
3. Educate patient
• Hand hygiene
• Nail cutting techniques
• Early intervention
• Break the stigma of amputation
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Thank You
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