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INTRODUCTION

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

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