ortho

1. HAND
INFECTIONS8TH MAY 2016
Mentor: Dr Dinesh
Presented by: R. Nandinii

2. OVERVIEW:
◦ Paronychia
◦ Felon
◦ Pyogenic flexor tenosynovitis
◦ Deep space infections
◦ Human bite
◦ Animal bite
◦ Take home messages

3. Anatomy

4. Paronychia
◦ Infection of the lateral nail fold
◦ If Infection extends to the eponychium
(defined as the thin membrane
distal to the nail wall at the base
of the nail), it is properly termed
an eponychia.
◦ When infection involves both lateral
nail folds and eponychium, it is called a
run-around infection

5. ◦ In adults, Staphylococcus aureus is the most common pathogen
◦ Pathophysiology
◦ Infection occurs when there is violation of the seal between the nail plate and nail fold,
allowing the inoculation of bacteria.
◦ Risk Factors
◦ Hangnails,
◦ Manicures,
◦ Penetrating trauma,
◦ Constant exposure to a wet or moist environment,
◦ Nail biting or sucking

6. Initial swelling,
erythema,
tenderness with
progression to
fluctuance, and
abscess formation
are typical.
Spontaneous
decompression can
occur, including
tracking beneath
the nail plate
(subungual
abscess).
Deeper infections
can involve the
nailbed, pulp
space, and bone,
producing nailbed
destruction, felon,
or osteomyelitis
Clinical presentation

7. Treatment
◦ Early stage
◦ Oral antibiotics,
◦ Warm soaks
◦ Rest and observation
◦ Surgical decompression is the treatment of choice
◦ Decompression is performed by carefully entering the abscess cavity between the nail plate
and nail fold with a scalpel blade .
◦ A small wick is placed for 24 to 48 hours to prevent the incision from closing and recurrence
of the infection. The wick is removed, and saline warm soaks are begun

8. A: An infected lateral and proximal nail fold can be elevated by an elevator or scalpel. B: For extensive infections, a
relief incision(s) is made perpendicular to the edge of the nail fold to allow for removal of a portion or all of the nail
plate. (Reprinted from Seiler JG. Essentials of hand surgery. Philadelphia: Lippincott Williams & Wilkins, 2002, with
permission. Copyright American Society of Surgery of the Hand.)
Depending on the extent of the infection, a partial or complete
nail plate removal with or without lateral nail fold relief
incision(s) is performed.
The incision should be made perpendicular to the edge of the
nail fold.
A single or double incision is used depending on the location of
the infection
Subungual abscesses are treated with removal of a portion of or
the entire nail. The abscess is carefully debrided while protecting
the sterile and germinal matrices

9. (A) Elevation of the eponychial fold with flat probe to expose the base of the nail. (B) Placement of an incision to
drain the paronychium and to elevate the eponychial fold for excision of the proximal one-third of the nail. (C-
E) Incisions and procedure for elevating the entire eponychial fold with excision of the proximal one-third of the
nail. A gauze pack prevents premature closure of the cavity.

10. ◦ Chronic paronychia
◦ Chronic paronychia occurs more commonly in
individuals constantly exposed to moist environments.
◦ Infections may be intermittent; clinically, the
eponichial fold is thickened and painful
◦ Candida albicans is a frequent offending organism
◦ Topical antifungal ointments are generally used 4 to 6
weeks.
FIGURE 2. Eponychial marsupialization is performed by removing a small, crescent-
shaped portion of the eponychial fold proximal to the distal edge of the eponychial fold.
Care is taken to not injure the underlying germinal matrix. (Reprinted from Seiler JG.
Essentials of hand surgery. Philadelphia: Lippincott Williams & Wilkins, 2002, with
permission. Copyright American Society of Surgery of the Hand.)

12. Felon
◦ A felon is a deep space infection or abscess of the
distal pulp of the finger or thumb.
◦ It differs from the superficial apical infection
involving the distal portion of the pulp skin, which
often responds to a small, deroofing incision
◦ The organism most frequently cultured from a pulp
space infection is S. Aureus

13. Felon
Pathophysiology
◦ Infection typically is due to direct inoculation of bacteria by penetrating
trauma but may be caused by
◦ hematogenous spread
◦ local spread from an untreated paronychia.
◦ Most common in thumb and index finger.
Clinical presentation
◦ Throbbing pain and
◦ Tense swelling localized to the pulp

14. Felon
“Don’t wait for fluctuation if tension is severe”
◦ Infection results in edema  increased pressure within the closed compartment
impaired venous outflow  local compartment syndrome
◦ Untreated felons can:
 extend toward the phalanx --> osteomyelitis
 toward the skin --> draining sinus
 obliterate vessels ---> skin slough or necrosis
 suppurative flexor tenosynovitis or septic arthritis of the DIPJ

15. Treatment
If recognized early (mild cellulitis): soaks & Abx
Later (abscess formation): surgical drainage
 Usually process has been going on > 48 hrs.
Principles:
Avoid injury to nerve and vessel structures
Utilize an incision that won’t leave a disabling scar
Do not violate flexor sheath (stay distal)
Produce adequate drainage

16. • The best is a longitudinal incision over the area of
greatest fluctuance because it avoids
– Skin slough
– Digital nerve injury
– Creation of an unstable fat pad
• To avoid penetration of the tendon sheath, the
incision should not extend to the distal
interphalangeal crease.
 Incise on lateral aspect of digit 5mm dorsal & distal to
the DIP flexion crease
 Continue distally to a point 5mm away from the edge
of the free nail
 Deepen the incision with a clamp within a plane just
volar to the palmar cortex of the DP
Location of Incisions:
Index, middle & ring: ULNAR SIDE
Thumb & small: RADIAL SIDE

17. Additional measures
◦ Pus should be taken for C&S
◦ Initial empiric antibiotic coverage with a second-generation cephalosporin,
such as cefazolin, while awaiting culture identification and sensitivity is
usually adequate.
◦ Addition of gram-negative coverage is recommended in an
immunocompromised individual.
◦ Postoperative wound care, edema control, splinting, and motion
optimization are preferably pursued with therapy supervision

18. Pyogenic flexor tenosynovitis
Anatomy
 Flexor sheaths are closed spaces
 Extend from the mid-palmar crease
to the DIPJ
(Prox edge of A1 pulley to distal edge of A5 pulley)
 Flexor sheath of small finger is
continuous proximally with the
Ulnar Bursa, while the sheath of
the thumb is continuous with the
Radial Bursa
 Radial & Ulnar bursae extend
proximal to the TCL and connect
with the Parona space
(Potential space between FDP & PQ muscle)

19.  Flexor sheath infections most often as a result of penetrating trauma
 More likely at joint flexion creases
 Sheaths are separated from skin by only a small amount of subcutaneous tissue here
 Also, Felons can rupture into the distal flexor sheath
 Usual causative agent: S. Aureus
 Most commonly affected digits:
 Ring, long & index fingers
Purulence within the sheath destroys the gliding mechanism, rapidly creating
adhesions that lead to loss of function
Destroys the blood supply producing tendon necrosis

20. Clinical
Kanavel’s 4 cardinal signs:
 Tenderness over & limited to the flexor sheath
 Symmetrical enlargement of the digit (“fusiform”)
 Severe pain on passive extension of the finger (>
proximally)
 Flexed posture of the involved digit
Not all four signs may be present early on
Most reliable sign: pain w. passive extension
Cellulitis of the hand may appear similar, but
swelling & tenderness is not usually isolated to a
single digit

21. Treatment
Early infection < 48 hrs (& usually lacking all 4 signs) may initially be treated with IV
Abx, splinting & elevation
Failure to respond within 24 hrs. should necessitate drainage
Established pyogenic tenosynovitis
is a surgical emergency
Requires prompt surgical drainage
Delays may result in tendon
&/or skin necrosis

22. Treatment
2 basic approaches:
Open vs. Closed
Open drainage:
Decompression of the entire tendon
sheath via mid-axial & palmar incisions
Wounds are left open to drain & heal
secondarily
Rehab is prolonged; permanent finger
stiffness not infrequent
Most useful for advanced cases where
resection of necrotic tendon is required

23. Treatment
 Closed tendon-sheath irrigation:
 2 incisions made
 Proximal palm: open the sheath proximal to the A1 pulley
 Distal mid-axial: open sheath distal to the A4 pulley
 Long irrigation catheter (16 - 18g) is placed in the proximal sheath
with a drain left in the distal incision
 Incisions are then closed, and sheath is irrigated for 48 - 72 hrs.
 May use NS or Abx solution (continuous drip or q2h flush)
 Addition of marcaine alleviates pain of irrigation
 Modification involves multiple transverse incisions of cruciate
pulleys with insertion of silastic drains

24. Chronic Tenosynovitis
Unusual cases may be seen which present differently than acute pyogenic infections:
 Chronic swelling of the flexor sheath
 No disabling pain or loss of function
These are chronic infections most frequently caused by mycobacteria
 usually the result of a puncture wound in an aquatic environment
 M. Kansasii or M. Marinarum
Dx: AFB stains & culture of synovium
Tx: tenosynovectomy + antituberculous drugs (6 - 24 mo)

25. Deep Space Infections
4 deep spaces clinically significant in hand infections:
Subfascial palmar space
Dorsal subaponeurotic space
Thenar space
Midpalmar space

26. Deep Space Infections
Subfascial Palmar Space Infections
 subfascial palmar space communicates with the dorsal subcutaneous
space via web spaces between the digits
 usually spread dorsally (“collar button abscess”)
 Double abscess: +/- palmar & dorsal abscesses connected through
hole in fascia
 Palmar spread is limited by the relationship of fascia to skin
 Causes:
 Fissure in the skin between the fingers
 Distal palmar callus (MC head)
 Extension from subcutaneous infection in proximal finger
 Severe distal palmar swelling with an abducted finger
 Puss-filled web spaces

27. Subfascial Palmar Space Infections
Treatment
2 important points:
Do not incise web space transversely
Be alert for the double abscess
configuration
Drainage is via a palmar approach with
division of the palmar fascia to expose
both the volar & dorsal compartments

28. Deep Space Infections
Dorsal Subaponeurotic Space Infections
 DSS is beneath the extensor tendons on the dorsum of the
hand
 Often the result of penetrating trauma
 neglected human bites
 Dorsal swelling, erythema & tenderness + history make the
diagnosis
 Drain via linear incisions over the 2nd & 4th MC’s while
preserving soft tissue coverage over the tendons
 occasionally direct incision over a pointing abscess is
necessary
 Risks exposure (desiccation) of extensor tendons

29. Deep Space Infections
Thenar Space Infections
 Thenar space follows the direction of Adductor Pollicis:
 Dorsal: AP muscle
 Volar: index flexor &
1st lumbrical
 Radial: insertion of AP
(proximal phalanx of the thumb)
 Ulnar: oblique septum from
skin to the 3rd MC

30. Thenar Space Infections
Clinical
 Causes:
 penetrating injury
 thumb or index subcutaneous abscess
 thumb or index flexor tenosynovitis
 extension from radial bursa or
midpalmar space
 marked swelling of the thenar
eminence & 1st web space
 thumb forced into abduction
 severe pain with extention or opposition
 infection tracks dorsally via 1st web space,
over the AP & 1st dorsal interosseous muscles.

31. Thenar Space Infections
Treatment
 Drain via volar or dorsal incisions
in the 1st web space or both:
 Identify neurovascular structures
 unroof the adductor fascia to open
the abscess cavity
 irrigate & debride
 catheter in volar incision & close;
penrose in dorsal incision & close
 compressive dressing & plaster splint

32. Deep Space Infections
Midpalmar Space Infections
 Boundaries:
 Dorsal: intrinsic muscles
 Volar: flexor tendons
 Radial: oblique septum from
the skin to the 3rd MC
 Ulnar: hypothenar muscles
 Distal: vertical septa of palmar fascia
 Prox: fascial layer at distal carpal tunnel

33. Deep Space Infections
Midpalmar Space Infections
 Clinical:
 usually due to direct
penetrating trauma,
rupture of tenosynovitis
 loss of palmar concavity,
dorsal swelling, tenderness
volarly

34. Midpalmar Space Infections
Treatment
 Drain via wide palmar incisions
with +/- resection of palmar fascia
to ensure drainage of abscess cavity.
 or may place irrigation catheter &
drain and close primarily.

35. Bursal Infections
 Usually due to spread of flexor
tenosynovitis from thumb or small finger
 Radial bursa:
 Proximal extension of
tendon sheath of FPL
 extends through the carpal
tunnel into the distal forearm
 Ulnar bursa:
 Proximal extension of tendon
sheath of FDP of small finger

36. Bursal Infections
Treatment
Closed irrigation using 2
incisions, a catheter & a drain
as previously outlined.

37. Human Bites
Often undertreated & misdiagnosed leading to significant morbidity
The most serious form of human bite infection is the clenched fist injury:
Any laceration over the head of a metacarpal is a human bite
injury until proven otherwise

38. Human Bites
The wound that results from a punch to the mouth may appear insignificant and
treatment may not be sought for days.
It often results in immediate inoculation of the subcutaneous tissue, the
subtendinous space and the MCP joint with saliva
 Human saliva may contain over 108 microorganisms per ml.
 Over 42 species of bacteria identified
 Thus: Polymicrobial infection is the rule
Common organisms:
 S. Aureus, Strep sp.,
 Eikenella: gram neg facultative anaerobe in ~ 30% (incr. severity)

39. Human Bites
Delay in onset of treatment is directly proportional to poor outcomes:
 In general, human bites treated within 24 hrs. rarely have serious complications
in E.D.:
 Debride, irrigate, pack open
 Abx to cover gram +’s & eikenella (Pen & Ceph)
 +/- admission to follow response
To O.R.:
 Established joint space penetration, & more severe infections

40. Animal Bites
Dog more common than cat (5%)
 Cat bites are particularly virulent & can result in deep puncture wounds that are hard to clean
More than half involve kids
Basic principles of debridement & irrigation apply
 Deep puncture wounds are left open & may require extension
 Established infections are debrided & packed open
 Superficial lacerations may be loosely closed after irrigation
Common organisms:
 S. Aureus, Strep viridans, Pasturella (#1 in cats), anaerobes
Abx: ampicillin (Clavulin on outpatient basis)

41. Take home messages:
Not all hand
swellings are
cellulitis
PFT is a
surgical
emergency
Remember 4
Kanavel’s sign
If swelling
doesn’t
subside in
24h…I&D
Most common
organism
Staph Aureus

42. THE END