2. Objectives – to make you understand:
• Overview of hand infection
• Types of hand infections
• Clinical applications
• Treatment approach
• Post operative patient care
4. Introduction
• Hand infections encompass a diverse array of diagnoses with
diverse etiologies
• Results in pain, disability and loss of productivity
• The fingertip is the most common site for hand infections
• High index of suspicion to diagnose and treat
5. ANATOMY
FASCIA OF THE PALM AND COMPARTMENTS
• Continuous with antebrachial fascia and the fascia of the
dorsum of the hand
• It is thin over the thenar and hypothenar
• Thick centrally (palmaraponeurosis and in the fingers (digital
sheaths)
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6. SPACES OF THE HAND
A.PALMAR SPACES
Pulp space of the fingers
Mid palmar space
Thenar space
B.DORSAL SPACES
Dorsal subcutaneous space
Dorsal subaponeurotic space
C.THE FOREARM SPACE OF PARONA
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10. Epidiomology
• Account for up to 35% of patients admitted to hand surgery services
• The fingertip is the most common site for hand infections
• The most frequent cause of major hand infections is a neglected
wound
11. Factors that impact the severity of infections
• Anatomic location
• Virulence of the organism
• Viability and vascularity of the surrounding soft tissue
• Timing of intervention
• Health status of the patient
12. Causative organisms
• Staphylococcus aureus
• 80% of all infections
• Rising incidence of MRSA
• Streptococcus species
• Many infections (Intravenous drug abuse, farm injuries, bite
wounds,immunocompromised pts) are polymicrobial
• Specifics
• Human bite – Eikenella corrodens
• Animal bite - Pasteurella multocida.
• Fishing/swimmer - Mycobacterium marinum
• Antibioticinitiated after Gram stain and cultures are obtained
15. General Approach
• Early recognition and intervention can
greatly improve outcomes
• Hx
Pain
Erythema
Edema
Fluctuance and tenderness
P/E-Examine entire extremity
Ix
• Laboratory
WBC
ESR
CRP
• Imaging
X-RAY
CT
MRI
16. General Managment
• Antibiotic therapy
• Tetanus prophylaxis
• Splinting
• Elevation
• Antipain
• Hand therapy
• Surgery
17. Fingertip
Paronychia
• Infection of the soft tissues around the nail fold(runaround)
• Accounts for 30% of all hand infections
• Commonly caused by Staphylococcus aureus followed by Streptococcus and
Pseudomonas
• Can be acute ( pain, swell, erythema) or chronic
• Risk factors:
• Manicures,hangnails, or nail biting
18. TREATMENT
• Mild cases- antibiotics
• Abscess formed:
Elevate nail fold
Drain and irrigate
Remove nail plate
19. Chronic paronychia
• After 6 weeks(C. albicans)
• Fingertip prolonged exposure to wet
• Thickened, indurated, and erythematous tissue proximal to
the nail plate
• Nail plate thickened and discolored
• Eponychial fold may retract
20. Rx:
• Avoid environmental triggers
• Topical steroid or antifungal
• Eponychial marsupialization
• Swiss roll technique
21. Post op care
• Oral antibtics-cephalexin or erythromycin
Culture posetive - 2 weeks.
Cilture Negative - 3 to 5 days
• Soak the finger in hydrogen peroxide
22. Herpetic whitlow
• Herpetic whitlow is a viral infection
HSV 1-60%
HSV 2 -40%
• It is caused from a viral inoculation of the host via infected
body fluids
• Symptoms -painful, burning ,tingling sensation , erythema edema and
vesicles
• Usually self limiting
23. Felon
• Infection in the subcutaneous pulp space of the fingertip
• Most commonly by S aureus
• Confined in matrix of vertical fibrous septa
• Painful and tender swelling
• Mostly present with abscess
• Drain:
• Longitudinal incision
• Midaxial incision
• Radial of small and thumb
• Ulnar of index, middle and ring
24.
25. POSTOPERATIVE CARE
• The finger is splinted, and elevation is maintained
• Antibiotic adjusted based on culture result
• Patients with diabetes or immunosuppression may be difficult to
control, and amputation may be the end result
26. Finger
Pyogenic flexor tenosynovitis
• Infection involving the closed flexor tendon sheath
• Common source of infection is direct inoculation
• Increased pressure affect vascular supply and gliding
• Horseshoe abscess- via space of Parona
27. Kanavel’s signs include:
• Fusiform digit
• Flexed resting posture of digit
• Tenderness over the flexor
tendon sheath
• Pain with passive extension
of the digit
28. Treatment
• Surgery:
• Limited exposure and catheter irrigation
• Extensive open dissection
• Proximal - proximal to A1 pulley
• Distal - midaxial or volar zigzag
• Irrigate from proximal to distal.
• Relook within 24-48hrs
• Early Active and aggressive hand therapy.
• Poor outcome in delayed, older, DM
SC purulence, ischemia and polymicrobial
29.
30. Post Op care
• Irrigated wound with 30 mL of saline every 2 hours
• Check for catheter patency
• Remove dressing after 48 hours examined the hand
• If drainage persists, irrigation may be necessary for several days
31. Hand
Deep space infections
• Include the subaponeurotic, thenar, midpalmar, hypothenar,
interdigital webspace, and Parona’s spaces
• Most infection is by direct inoculation
• Antibiotics, Incision, irrigation and debridement are the mainstay of
management
32. Subaponeurotic space
• Edema and erythema of dorsum of hand
• Dorsal- extensor tendons
• Volar – metacarpals and interosseous muscles
• Exposure- dorsal longitudinal incision
33. THENAR SPACE INFECTIONS
Causes:
• Penetrating injury
• Thumb or index subcutaneous abscess
• Thumb or index flexor tenosynovitis
• Extension from radial bursa or midpalmar space
34. Clinical features
• Thumb forced into abduction
• Severe pain with extention or opposition
• Infection tracks dorsally via 1st web space
• Marked swelling of the 1st web space
• Thenar eminence
35. • Drain via volar or dorsal incisions in the 1st web space
• Identify NV structures
• irrigate & debride
• Put catheter in volar incision
36. Hypothenar space
• Infection is extremely rare
• Radially by the hypothenar septum
• Deep and radial to hypothenar muscles
• Superficial to small finger metacarpal
• Longitudinal incision used for drainage
37. MID PALMAR SPACE INFECTIONS
• Loss of the normal palmar concavity
• The long and ring fingers assume a partially flexed posture
• Tenderness over passive extension of these fingers
38.
39. WEB SPACE INFECTION (COLLAR
BUTTON ABSCESS)
• Infection in one of second, third and fourth interdigital web spaces
• Affected webspace are held in abduction position
• Volar and dorsal incisions are advocated for adequate drainage of this
space
• Direct incision through the webspace should not be performed to avoid
adduction contracture
40. SPACE OF PARONA
• Deep to the flexor tendons
• Superficial to the pronator quadratus muscle
• Contiguous with the radial and ulnar bursae
• Significant forearm edema,tenderness and pain with finger flexion
• Drain via longitudinal incision on the ulnar aspect of the forearm
• Hand should be splinted, elevated and closely monitored
• Relook after 24-48hrs depends on clinical improvement
41. Complication of deep space infection
• Stiffness and contracture
• Skin necrosis either dorsally or volarly.
• Tendon necrosis
• Soft tissue necrosis and distortion of local anatomy
42. Summary
• Early recognition and intervention of hand infection improve outcomes
• It is Important to identify risk factors to obtain baseline lab work, X-rays, and
blood cultures
• Appropriate antibiotic coverage should be chosen based on the severity of
infection and the exposure history
• Pyogenic flexor tenosynovitis warrants urgent surgical intervention.
43. References
• Neligan principle of PRS-4th edition
• Green's Operative Hand Surgery_7th edition
• Grabb and Smith’s Plastic Surgery- 8th Edition
• Michigan manual of plastic surgery
• Uptodate online
