Infection of the hands is frequently limited to one of
several well defined compartments: Under the nailfolds (paronychia) The pulp space Subcutaneous tissue Tendon tissue One of deep fascial space/joint Aetiology : 90 % Staphylococcus aureus
PATHOLOGY Acute inflammation or suppuration in small closed compartment(tendon sheath or pulp) >increase pressure > can cause local blood supply threatened
Severe case : tissue necrosis
CLINICAL FEATURE Painful and tensely swollen Ill and feverish Throbbing pain Obvious redness and tension in the tissue Tenderness over site of infection Restricted finger movement
TREATMENT 1- ANTIBIOTICS immediately started e.g. Flucloxacillin In severe case : fusidic acid 2- REST AND ELEVATION Mild case : rested in sling Severe case : elevated in roller towel while the patient is admit for observation.Analgesic give for painkiller 3- SUPPURATION Sign of abscess(sign of infection,marked tenderness,&toxaemia) > drainage of the pus Tourniquet & general or regional block anaesthesia Incision made at site of maximal tenderness Pus specimen sent for microbiological specimen
TREATMENT SPLINTAGE Removable splintage applied if after draining tendon sheath or fascial space infections or if conservative treatment prolonged Always with the joints in the position of safe immobilization Wrist slightly extended , the MCP joints in full flexion , the interphalangeal joints extended and thumb in abduction
PHYSIOTHERAPY SPECIFIC TYPES OF INFECTION 1) Cutaneous & sub-cutaneous infections: Paronychia Pulp Space Infection (Felon) 2) Infection of the tendon with its synovial sheath tenosynovitis. 3) Fascial spaces infection : Deep Space Infection i.e. midpalmar space & thenar space 1) PARONYCHIA Anatomy Most common infection in the hand Localized superficial infection or abcess of the lateral nail fold Typically is due to superficial trauma (e.g. hangnails, nail biting, dishwashing,finger sucking). The area of infection will be swollen, red and tender TREATMENT Early sign of infection antibiotics If the pus present Lifting the nailfolds from the nail If severe infection with purulent drainage beneath nail, requires removal of a portion of the nail
A scalpel (knife) is inserted under the skin at the edge of nail to open the pus pocket and drain it to relieve the pressure and treat the infection The doctor pushes on the swollen area to get the pus out after the incision was made with the scalpel. the doctor pushes on the swollen area to get the pus out after the incision was made with the scalpel. 2) PULP SPACE INFECTION (FELON) DEFINITION subcutaneous tissue of the pulp space of the distal phalanx
ANATOMY The fingertip pulp, compartmentalized by 15 to 20 fibrous septa running from the periosteum to the skin. The small compartments contain eccrine sweat glands and fat globules. The sweat glands provide a potential portal of entry for bacteria. An abscess in these noncompliant compartments is called a felon.
PULP SPACE INFECTION (FELON) Clinical feature fingertip swollen, red and tender Mode of infection Infection typically is due to direct inoculation of bacteria by penetrating trauma(prick/splinter) but may be caused by hematogenous spread and by local spread from an untreated paronychia. Treatment Antibiotics Incision over site of tenderness
OPERATIVE METHODS The best is a longitudinal incision over the area of greatest fluctuance. To avoid penetration of the tendon sheath, the incision should not extend to the distal interphalangeal crease.
3) OTHER SUBCUTANEOUS INFECTION Blister or superficial cut may become infected Clinical feature : redness, swelling and tenderness Treatment : local collection of pus Drained through small incision over the site of maximal tenderness. This is to exclude a deeper pocket of pus in an nearby tendon sheath or in one of deep fascial space.
4) TENDON SHEATH INFECTION ANATOMY o Flexor sheaths are closed spaces o Extend from the mid-palmar crease to the Distal Interphalangeal joint o Flexor sheath of small finger is continuous proximally with the Ulnar Bursa, while the sheath of the thumb is continuous with the Radial Bursa o The synovial sheaths, poorly vascularized and rich in synovial fluid, provide an optimal environment for bacterial growth. MODE OF INFECTION o Once inoculated, infection can spread rapidly within the confines of the sheath.
o Infection of the flexor tendon sheath, known as pyogenic flexor tenosynovitis.
PYOGENIC FLEXOR TENOSYNOVITIS
o Kanavels 4 cardinal signs:
oTenderness over & limited to the flexor sheath oSymmetrical enlargement of the digit (fusiform) oSevere pain on passive extension of the finger (> proximally) oFlexed posture of the involved digit
o Treatment oSplint and elevate oAdminister IV antibiotics oIf theres no improvement within 24 hours,consider surgical drainage oTwo incision are needed oProximal palm oDistal mid-axial othe sheath is irrigated with saline or Ringers Lactate . oThe catheter is left in place for post operative irrigation during next 2 days oAt the end of operation, the hand is dressing and splinted in the position of safe immobilization
Most reliable sign: pain with passive extension 5) DEEP FASCIAL SPACE INFECTIONS Infection for a web space or from infected tendon sheath may spread to either of deep fascial spaces of the palm Clinical feature : the palm is balloned,so its normal concavity is loss Extensive tenderness and whole hand is held still 4 deep spaces clinically significant in hand infections: Subfascial palmar space Dorsal subaponeurotic space Thenar space Midpalmar space Treatment For drainage, incision is made directly into the abscess and sinus forceps inserted Postoperatively, the hand is dressed and splinted
Thenar space infection. Four days after a puncture wound of the thenar crease there is pain, tenderness, swelling and restricted movement. The mid- palmar space was also involved. Midpalmar Space Infections Collar stud abscess resulting from stabbing of the thenar crease with an indelible pencil. The deep component of this abscess was in the midpalmar space which became tender and swollen. The middle finger is flexed because of involvement of its tendon sheath. Web Space Collar Button Abscess A dorsal thenar web space infection Thenar space infection
Hunter LPN, Laura - Walker RN BSN, Jennifer - Moms On Call - Basic Baby Care 0-6 Months - Parenting Book 1 of 3 (Moms On Call Parenting Books) (2012, Mo