HAND INFECTIONS

HOW TO IMPROVE OUR

MANAGEMENT ?

Christian Dumontier, MD, PhD & Sylvie Carmès MD

Hand Center, Guadeloupe, FWI
 HAND INFECTIONS ARE FREQUENT…
SO ARE THE COMPLICATIONS

• Rate of (minor) hand injuries

is high, rate of infection is low

• Cause of hand infection:

direct trauma (50%), human
bites (30%) animal bites
(10%), drug injections (10%°

• 2/3 males, 1/3 females, mean

age 40 years, mean delay
between surgery 10 days.
PATHOPHYSIOLOGY OF HAND INFECTION:
4 STAGES

Inoculation

Inflammation

Abscess
• Complications are said to occur in 5%
of cases, in 33% of our cases
Complications
Dorfmann A, Carmes S, et al. Advanced nger infection: more frequent than expected and mostly iatrogenic. HSR 2021; 40:326-330
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 INOCULATION
• Apart lavage and skin disinfection, no
other treatment can be done

• Antibiotics are not indicated

• The vast majority of skin breaks

does not ended up with an
infection

• It would be extremely expansive

• It would increase antibioresistance

• Allergic risks

West RM et al: 'Warning: allergic to penicillin': association between penicillin allergy status in 2.3 million NHS general
practice electronic health records, antibiotic prescribing.. J Antimicrob Chemother. 2019 Jul 1;74(7):2075-2082
 INFLAMMATION STAGE

• Local in ammatory signs:

Redness, swelling

• Spontaneous pain, less

severe at night,

• Non-operative treatment
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 INFLAMMATION STAGE: NON-
OPERATIVE TREATMENT
• Hand elevation (limit swelling and
edema)

• Rest (Avoid diffusion of germs)

• Hexomedin®, Dakin, Alcoohol soaked Patient burned by Dakin

dressings

• (Antibiotics): Antibiotics may be helpful

but we discourage its use (to be
discussed)

• Repeated evaluation: if no dramatic

improvement, proceed to surgery

Pilcher RS, Dawson RL. Infections of the ngers and hand. Lancet 1948;1:777–83
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 ABSCESS
• Pain, intense, pulsatile, permanent,
increased at night

• Tense, red, hot skin -Sometimes the

pus is visible

• May have epitrochlear or axillary

ganglia, lymphangitis,

• Fever, ➚ SR, ➚ CRP,

Hyperleucocytosis (blood tests are
useless)
 ABSCESS
• Make a X-ray +++

• Proceed to the OR

• « The rst night without

sleeping is an indication
to surgery »
Kanavel-1905

• Ubi pus, ibi evacuat (Am

Med J 1876)
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 ABSCESS STAGE = THE KNIFE IS THE ONLY
SOLUTION

• Complete excision of the entry

wound, and of all dead or infected
tissues = Large debridement

• Take a bacteriological sample

• Lavage

• Do not close wounds

• (Antibiotics may be used)

• Close follow-up
 LAVAGE
• With serum (no antiseptic,
no Hydrogen peroxyde,…)
• No hyper-pressure
• Adequate volume:
« Dilution is the solution to
pollution ».
I have treated many wounds with only
water being at war with no other remedies
and got good successes. I cannot give you
the explanation but I believe that clean
wounds can heal and water cleans and
debrides wounds
Ambroise Paré, King of surgeons and
surgeon of kings
 DO NOT CLOSE WOUNDS

• O2 is very detrimental to all

germs +++

• Persistent germs will

multiply themselves after
closure

• No indications for drains

(non-vascularized dead
bodies)
 ANTIBIOTICS CAN BE USED
• Abscesses are poorly accessible to antibiotics
(collagen brous wall)

• They are not vascularized; antibiotics

penetration is only possible through
permeation (17-53% of serum level)

• In an abscess, antibiotics are less active (zinc

concentration, maturation phase of germs,
poor O2 tension,…) Pus
Bartlett JG: Experimental aspects of intraabdominal abscess. Am J Med 1984;76:91–98
Joiner KA, Lowe BR, Dzink JL, Bartlett JG: Antibiotic levels in infected and sterile subcutaneous abscess in mice. J Infect Dis 1981;
143: 487-494.
Barza M: Pharmacokinetics of antibiotics in shallow and deep compartments. J Antimicrob Chemother 1993;31(suppl D):17–27.
Wagner C et al. Principles of antibiotic penetration into abscess uid. Pharmacology 2006;78(1):1-10
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 POSTOPERATIVE PRESCRIPTION OF ANTIBIOTICS

• 90% of our 125 patients were cured without antibiotics (only surgery)

• 45 of 46 withlows were cured w/o postoperative antibiotics

• 99,6% of Staph Aureus infection with an inappropriate antibiotic were

cured

• No difference in children w/wo antibiotic use in Staph Aureus Methy R

infection (96% cured)

Pierrat J et al. Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46 patients.
Hand Surg Rehabil. 2016;35(1):40-3.
Paydar KZ et al. Inappropriate Antibiotic Use in Soft Tissue Infections. Arc Surg 2006;141:850-856
Lee MC et al. Management and outcome of children with skin and soft tissue abscesses caused by community-acquired
methicillin-resistant Staphylococcus aureus . Pediatr Infect Dis J 2004; 23:123–127.
 THE FOLLOW-UP

• Early (2-3 days)

• Lavage

• Repeated every other day ?

• Early rehabilitation
 COMPLICATIONS
• Extension of the infection into closed spaces
(joints, sheaths), bone, anatomical spaces of
diffusion.

• Late presentation (p < 0,001)

• Inadequate treatment (Antibiotics, NSAID’s,

inadequate drainage, wound closure…) (p =
0,05)

Inadequate patient ? (diabetics, immune- Majo

• r
de cient, …) - controversial osteit
is
• Inadequate germs ?

• Death ? 3% for digital sheath infection, 7% for

hand spaces infection in 1942…very rare
today but complications can be very disabling
• A thumb’s felon of a 23 years old male after 2 weeks of MP U TATION
A
treatment by ATB + NSAIDs leading to distal thumb
amputation
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 WHICH TYPE OF COMPLICATIONS ?

• Secondary osteitis: 39%

• Secondary septic flexor tenosynovitis:

37%

• Secondary septic arthritis : 15%

• Extension of the infection to the digit

and/or to the hand : 15%

• Extensive necrosis: 12%

Some patients having multiple complications, the sum is superior to 100%

 THE GERMS
« Not
Germs « Complicated» Chi2
complicated »

Staphylococcus Aureus
34 (40 %) 9 (22%) p= 0.04
(34%)
• Staphylococcus aureus 30-80% Gram - bacteriae (33%) 17 (20%) 10 (24%) NS

Polymicrobial (11%) 8 (10%) 6 (15%) NS

• Streptococci (10-20%) Sterile (7%) 5 (6%) 3 (7%) NS
Missing data or Rare
20 13 NS
germs
• Gram- strains (20%)

• Polymicrobial = necrosis

• Negative 10-20%
SOME EXAMPLES OF HAND
INFECTION AND THEIR
MANAGEMENT
 PERI-UNGUEAL INFECTION

• Diagnostic is easy

• Mostly Staphyloccus aureus

• Drainage without anesthesia

most often suf cient

• Surgical excision under local

anesthesia and digital
tourniquet
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 PERIONYCHIUM
• Extend along the proximal
nail fold

• May diffuse

• Dorsum of the nger

• Under the nail plate (rare)

• Into the pulp under Flint’s

interphalangeal ligament
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 PULP INFECTION (FELON)
• Clinical diagnosis dif cult (pus may not
be visible - a tense pulp is diagnostic),
usually very painful

• Mostly Staphylococcus aureus

• Early diffusion to bone (due to pressure)

• Direct incision

• Excise bone if needed

• Leave open
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 FINGER INFECTION

• Large excision (extensor

tendon)

• Beware of diffusion along

pedicles or exor tendon
sheath

• Leave open +++

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DORSAL DIFFUSION AT THE FINGER

• Rare (no real space)

• Phlyctenulae are more frequent

VOLAR DIFFUSION AT THE FINGER

• The exor sheath

• The anterior space

along the pedicles
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 ANATOMICAL SPACES OF THE HAND
- SURGICAL CONSEQUENCES

• Deep, clearly delineated

• 3 spaces at the hand: Thenar,

mid-palmar & hypothenar

• 1 space at the distal forearm

(space of Parona)

• Ulnar and radial sheaths

• Super cial, poorly limited

• Dorsal (sus or sub-

aponeurotic)

• Interdigital or web space

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 WEB INFECTION

• Clinical diagnosis
( nger abduction)

• Severe dorsal oedema

• Two incisions (beware

pedicle division, arteries
more distally than
nerves)
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FLEXOR SHEATH INFECTION
• Anatomy

• Clinical signs

• Bacteriology: most Staphylococcus aureus

• Due to penetrating wounds, diffusion (rare < 5%),

postoperative complication

• Surgical technique according to Michon

• Rehabilitation
FLEXOR TENDON SHEATH
• Many variations +++

• Communication with the ulnar sheath (367 cases)

• Index 5,1%

• Middle 4.0%,

• Annular 3.5%

• The sheath of II & III may arise from the radial sheath

• Isolated sheath for the index running from the wrist to

the distal phalanx !
 DIGITO-PALMAR SHEATHS
• The radial sheath and FPL
communicate in all subjects

• Radial exor sheath infection should be

opened 3-4 cm above the wrist crease
and at the IP joint
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ULNAR DIGITO-PALMAR SHEATH

• Ulnar sheath and the sheath

of the little nger
communicate in 80% of
individuals (Gardner), 50%
(Poirier & Resnick ), 71 %
(Scheldrup)

• But only 30% (Phillips)

Phillips CS et al. The exor synovial sheath anatomy of the little nger: a macroscopic study. J Hand Surg 1995;20A:636-641
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• 50% of the little nger
sheaths end at the
level of the palmar
transverse ligament

• 30% are in continuity

with the ulnar sheath

• 20% end at the level

of the A1 pulley

Phillips CS et al. The exor synovial sheath anatomy of the little nger: a macroscopic study. J Hand Surg 1995;20A:636-641
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 DIGITO-PALMAR SHEATHS

• Radial and ulnar sheath

communicate at the wrist in
50-80% of individuals

• Up to 85% of patients:
communication between
the radial, ulnar sheath and
the midpalmar space
 CLINICAL SIGNS ACCORDING TO THE ANATOMY

Fq +
• Kanavel cardinal signs

• Global nger swelling

• Pain ➚ with nger extension

PAIN
(the most sensitive) PAIN

• Finger in slight exion

PAIN
• Finger along the sheath, up
to the proximal cul-de-sac
(most spci c)
Fq -
The 4 signs were present in 54% of cases (Dailaina, JHS 2008)
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 SIGNS OF GRAVITY
• Age > 43 years
Group 1: No ischemia and
• Comorbidity (Diabetes, Renal failure, no subcutaneous diffusion:
peripheral vascular insuf ciency) No amputation, 80 TAM
Group II: Subcutaneous
• Subcutaneous diffusion of the infection
diffusion without ischemia:
8% amputation, 72% TAM
• Digital ischemia at presentation
Group 3: subcutaneous
• Late treatment diffusion with ischemia:
59% amputation, 49% TAM
• Polymicrobial infection

Pang H-N et al. Factors affecting the prognosis of pyogenic exor tenosynovitis. J Bone Joint Surg 2007;89A:1742–1748.
Dalaina Z. JHS 2008
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SURGICAL TREATMENT IS AN EMERGENCY

• According to Michon’s stages

• Stage 1: Distension of the digital

sheath, clear or « louche »

• Stage II: Pus with localized (Stage

2a) or diffuse (2b) synovitis

• Stage III: Tendon involved, necrotic

 STAGE I
• Excise entry portal

• Take bacteriological samples

• Incision proximal cul-de-sac

• Proximo-distal lavage with

saline

• Leave incisions open

• Control D2, early

rehabilitation
 STAGE II
• Excise entry portal

• Take bacteriological samples

• Extended Brunner Incisions

• Synovectomy, protect A2A4

• Leave incisions open

• Control D2, D4, early

rehabilitation
 DEEP SPACES OF THE HAND
• Thenar

• Mid-palmar

• Hypothenar:

• Very rare, after wounds

• No possible expansion

• Localized pain and swelling

(not dorsal)
 DEEP SPACES OF THE HAND
• Thenar

• Mid-palmar

• Between the two: 3rd metacarpal, oblique fascia

between the 3rd metacarpal and the palmar fascia

Dorsal swelling AND

Palmar swelling and
pain
 MID-PALMAR SPACE
• Rare infection : either
penetrating wound or
expansion of a septic
tenosynovitis of IV/V

• Tense and painful palm

• Loss of palmar concavity

• III and IV nger in a

« reducible » position of exion

• Dorsal swelling
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 SURGICAL
CONSEQUENCES

• Surgical drainage is dif cult

because of the « rich »
anatomy

• Many possible incisions (do

it large)
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 THENAR SPACE
• Limits :

• Medial: oblique fascia

• Dorsal: fascia of adductor

pollicis

• Volar: Index sheath and palmar

fascia

• Radial : coalition of the palmar

fascia and the aponeurosis of
the adductor pollicis over the
1st phalanx of the thumb
 SURGICAL IMPLICATIONS
• No incision in the axis of the web
(retraction) - Two incisions

• Do not forget to drain up to the

middle of the palm +++
 SPACE OF PARONA (FRANCESCO PARONA, 1876)

• Limits are:

• Distal: Carpal tunnel

• Proximal: Flexor
super cialis muscles

• Dorsal: Pronator
quadratus and
interosseous membrane

• Volar: exor tendons

Sharma KS. Space of Parona infections. JPRAS 2013;66:968-972
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 CONCLUSION
• Be agressive !

• Bacteria multiply themselves

within half an hour

• Dead or infected tissues

cannot heal

• Being too agressive is rarely a

problem, being late or shy
leads to severe complications
 n
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Thanks
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Than k s fo r yo u r attent i r

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