HAND INFECTIONS

CATHERINA KLEYNHANS
 CONTENTS
1. INTRODUCTION
2. ANATOMY
3. PATHOPHYSIOLOGY
4. CLINICAL FEATURES
5. TREATMENT PRINCIPLES
6. COMPLICATIONS
7. TYPES:
1. NAIL-FOLD INFECTIONS (PARONYCHIA)
2. PULP INFECTIONS (FELON)
3. TENDON SHEATH INFECTIONS (SUPPURATIVE TENOSYNOVITIS)
4. DEEP FASCIAL SPACE INFECTIONS
5. SEPTIC ARTHRITIS
6. BITES
7. MYCOBACTERIAL INFECTIONS
8. FUNGAL INFECTIONS
9. NECROTIZING FASCIITIS
INTRODUCTION
Infections of the hand are common, particularly in immunocompromised patients, and can
lead to significant morbidity, including amputation, if not treated properly. Hand infection
can spread from the original site of inoculation through interconnections between the
synovium-lined and non-synovial potential spaces.
The infections are limited to one of several well-defined compartments:
Under the nail-fold (paronychia)
The pulp space (felon)
In the subcutaneous tissues
Deep fascial spaces
Tendon sheaths
Joints
Staphylococcus is the most common cause, implanted during trivial injury, but
contaminated cuts by unusual organisms also occur and account for about 10% of cases
ANATOMY
ANATOMY
ANATOMY
ANATOMY
PATHOPHYSIOLOGY
The response to infection is an acute inflammatory
reaction with oedema, suppuration and increased tissue
tension.
In the closed tissue compartments, the pressures may rise
to levels where the local blood supply is threatened, and
the risk of tissue necrosis occurs.
There is also the rare but severe case of lymphatic and
haematological spread leading to septicaemia and
lymphangitis.
TYPE OF INFECTION COMMON CAUSATIVE ORGANISMS

Cellulitis S aureus, Streptococcus species

Necrotizing fasciitis Streptococcus species, polymicrobes

Abcess (paronychia, felon, deep space S aureus

infection)
Flexor tenosynovitis S aureus, anaerobes

Septic arthritis S aureus

Human bite S aureus, Streptococcus species, Eikenella

corrodens, anaerobes

Animal bite Pasteurella multocida, S aureus, Streptococcus

species
CLINICAL FEATURES
There is usually a history of trauma (a superficial abrasion, laceration or penetrating
wound) but these may be so trivial that it passes unnoticed.
Hours or days later the finger or the hand becomes painful and swollen.
The patient may experience throbbing of the hand and in some cases feel feverish.
It is also crucial to enquire about predisposing conditions such as DM, IV drug abuse
and immunosuppression. *
On examination, the hand appears red, swollen and extremely tender over the site of
tension. However in immune-compromised patients, elderly and in babies these local
signs may be mild.
If theres superficial infection the patient can be persuaded to flex the finger whereas
with deep infections active flexion is not possible
Host factor Considerations

Diabetes mellitus Higher incidence of mixed and pure gram-negative organisms

(approaching 30 to 40 percent) requiring use of broader
spectrum antibiotics. Susceptible to more severe infections
and more likely to require surgical intervention.

Immunocompromised state More susceptible to opportunistic infections.

Pyogenic flexor tenosynovitis as well as cutaneous abscesses
are known potential sequelae of disseminated Neisseria
gonorrhoeae and are more common in patients who are
immunocompromised.

Intravenous drug use
Tropical fish aquarium exposure
Possible sexually transmitted disease exposure
Mixed aerobic and anaerobic hand infections are common
and usually caused by oral pathogens. Patients commonly
present with subcutaneous abscesses and tendon sheath
infections.
The culprit organism is more likely to be Mycobacterium
marinum. This organism is quite fastidious and often responsible
for chronic, indolent hand infections.
Flexor tenosynovitis as well as cutaneous abscesses are known
potential sequelae of disseminated N. gonorrhoeae infection.
CLINICAL FEATURES
Xrays are usually unhelpful in the initial
presentation of hand infections and may
only show a foreign body in some cases,
however a few weeks later Xrays may be
recommended to rule out important
complications such as osteomyelitis or
septic arthritis.
If pus becomes available- it should be sent
for MC&S
TREATMENT PRINCIPLES
The essentials of treatment include:
1. Antibiotics
2. Rest, splintage and elevation
3. Drainage
4. Rehabilitation
ANTIBIOTICS
As soon as a clinical diagnosis has been made (with or without specimen) antibiotics is
started.
Flucloxacillin or a cephalosporin
For bites: broad-spectrum antibiotics
Agricultural injuries: (anearobic organisms) metronidazole
These antibiotics can the be changed once the sensitivity is known.
TREATMENT PRINCIPLES
REST, SPLINTAGE AND ELEVATION
In a mild case the hand can be rested in a sling
In severe cases, the patient requires admission, with arm elevation, antibiotics and
analgesia
For optimal pain control the hand can be splinted for immobilization: with the wrist
slightly flexed, the MCP joints in flexion, with the IP joints fully extended and the thumb
abducted
Alternatively:
TREATMENT PRINCIPLES
DRAINAGE
If treated within the first 24-48 hours many hand infections will respond to antibiotics,
rest, elevation and splintage
If there are signs of an abscess (throbbing pain, marked tenderness, fluctuance and
toxaemia) the pus should be drained.
A general or regional block with tourniquet should be used
The hand should be exsanguinated by elevation only as exsanguination with a band
can spread the sepsis
The incision should be planned to give access to the abscess without causing injury to
other structures and never at right angles across a skin crease.
TREATMENT PRINCIPLES
TREATMENT PRINCIPLES
It is important to also look for deeper pockets of infection, excise necrotic tissue and wash
out the area thoroughly.
The wound is then left open or slightly sutured and covered with a non-stick dressing and
gauze
In some cases, a catheter has been used to be inserted into the wound once finished, this
catheter is then used post-operatively to irrigate the wound after 24 hours
Finally the hand is splinted, and a sling used to elevate the hand
Wound should be observed for atleast 24hours
POST-OPERATIVE REHABILITATION
As soon as the signs of acute inflammation have settled, the use of OT need to be utilized to
assist with hand mobilization and decrease joint stiffness.
The previously mentioned splint can be used within the first few days inbetween exercise
periods
COMPLICATIONS
Chondrolysis- early onset osteo-arthritis
Joint stiffness/contractures
Septicaemia
Chronic Osteomyelitis
Tendon shortening/rupture/adherence/necrosis
Compartment syndrome
Nerve impingement/Carpal Tunnel syndrome
Significant morbidity (poor compliance)
NAIL-FOLD INFECTIONS
(PARONYCHIA)
NAIL-FOLD INFECTIONS
(PARONYCHIA)
Infection is the commonest hand infection
It is seen most commonly in the extremes of age
The edge of the nail-fold becomes red and swollen and increasingly tender
A tiny abscess may form in the nail-fold if this is left untreated, the pus can spread
under the nail.
At the first sign of infection, treatment with antibiotics alone may be sufficient
If pus is present it requires drainage. An incision can be made at the corner of the
nailfold, in line with the edge of the nail, a paraffin gauze strip is then used to keep the
nailfold open
If the pus has spread underneath the nail, all or part of the nail needs to be removed
Chronic paronychia
PULP INFECTION (FELON)
PULP INFECTION (FELON)
The distal finger pad is a closed fascial compartment filled with compact fat and
subdivided by radiating fibrous septa
A rise in pressure within the pulp space causes intense pain and if unrelieved may
threaten the terminal branches of the digital artery which supply most of the terminal
phalanx
The most common organism is S. aureus, usually caused by a prick injury that becomes
infected
Treatment principles as above
If delayed or left untreated can spread to the bone, joint or flexor tendon sheath
PULP INFECTION (FELON)
HERPETIC WHITLOW
HSV my enter the finger tip, either by inoculation
by the patients own mouth or genitalia or by
cross infection during dental surgery
Small vesicles form on the fingertip, then
coalesce and ulcerate
The condition is self-limiting and usually subsides
after about 10 days
Acyclovir may be effective in the early stages
but surgical intervention is unhelpful and can be
harmful by exposing the finger to secondary
infection
TENDON SHEATH
INFECTION
(SUPPURATIVE
TENOSYNOVITIS)
TENDON SHEATH INFECTION
(SUPPURATIVE TENOSYNOVITIS)
TENDON SHEATH INFECTION
(SUPPURATIVE TENOSYNOVITIS)
The tendon sheath is a closed compartment extending from the distal palmar crease
to the DIP joint
In the thumb and the fifth finger the sheaths are co-extensive with the radial and ulnar
bursae, which envelop the flexor tendons in the proximal part of the palm and across
the wrist, these bursae also communicate with the Paronas space in the lower forearm
The affected digit is swollen and painful and is usually held in slight flexion. The patient
will not be able to move or allow movement of the finger
Delayed diagnosis leads to progressive rise in pressure within the sheath and a
consequent risk of vascular occlusion and tendon necrosis
Neglected cases can spread proximally within the radial/ulnar bursae, from one to
another (horse-shoe abscess), or proximal spread to the flexor compartment at the
wrist and into Paronas space in the forearm, occasionally this can lead to median
nerve compression.
TENDON SHEATH INFECTION
(SUPPURATIVE TENOSYNOVITIS)
TENDON SHEATH INFECTION
(SUPPURATIVE TENOSYNOVITIS)
Kanavels signs of flexor sheath infection:
1. Flexed posture of the digit
2. Tenderness across the course of the tendon
3. Pain on passive finger extension
4. Pain on active flexion
Treatment must be started ASAP, with antibiotics, elevation and splinting
If no improvement after 24hrs: surgical drainage by making 2 incision sites, one
proximally and one distally at the sheath, a fine catheter placed inside and irrigated
with R/L. Left inside and irrigated with 20ml of saline 3/4 times per day for 2 days
Stiffness is a real risk in these patients so early rehabilitation with movement assistance
should be arranged
DEEP FASCIAL SPACE INFECTION
The large thenar and mid-palmar fascial spaces may be infected directly by
penetrating injuries or secondary spread from a web space or an infected tendon
sheath
Clinical signs can be misleading as the hand is painful but because of the tight deep
fascia there may be little or no swelling of the palm, while the dorsum bulges
Treatment is commenced ASAP with antibiotics, elevation and splintage, for drainage
an incision is made directly over the abscess, if the web space is infected, it too should
be incised.
A thenar space abscess can be approached through the first web space or through
separate palmar and dorsal incisions around the thenar eminence.
The deep mid-palmar space can be drained through an incision in the web space
between the middle and ring fingers
These infections can also spread proximally and mimic median nerve compression
symptoms
DEEP FASCIAL SPACE INFECTION
SEPTIC ARTHRITIS
Any of the MCP or finger joints can be infected either by penetrating injury or intra-
articular injection or indirectly from adjacent structures
Pain, swelling and redness is limited to the affected joint
The presence of lymphangitis and/or systemic features may help make the diagnosis,
otherwise in their absence might be indistinguishable from acute gout. Joint aspiration
may also help with the diagnosis
Antibiotics is initiated with splintage, and if the inflammation doesnt subside within the
first 24hours, drainage is needed
For IP joints: dorso-ulnar or dorso-radial incisions are made between the collateral
ligaments and extensors
MCP joints: mid-dorsal incision is made
Dressings are applied and observed for 48 hours, with post-op rehabilitation, and a 2
week oral antibiotic course is continued on discharge
BITES
ANIMAL BITES
Inflicted by cats, dogs, farm animals or rodents, many become infected by common
pathogens Staph and Strep but also unusual organisms like Pasteurella multocida
Rabies is an important possibility in these cases
HUMAN BITES
Even more prone to infection, by wide variety of organisms: anaerobes, Staph, Strep
grp A and Eikenella corrodens
Tell-tale signs are wounds on the dorsal and volar aspects of the hand
All wounds need to be assumed to be infected
Xrays should be done to exclude fractures, tooth fragments or foreign bodies
All bite wounds are sensitive to broadspectum penicillins and cephalosporins
Tendon lacerations should be dealt with once tissues are completely healed
MYCOBACTERIAL INFECTIONS
Tuberculous tenosynovitis is uncommon, but should be suspected in patients with
chronic synovitis where alternatives like Rheumatoid disease has been excluded.
Treatment: synovectomy and prolonged chemotherapy
Fishmongers infection is a chronic infection by Mycobacterium marinum, introduced
by prick-injuries from fish spines or hard fins. It may appear like a granuloma, but deep
infection can give rise to intractable synovitis of tendon or joint
The recommended drug is broad-spectrum tetracycline or chemotherapy with
ethambutol and rifampicin
FUNGAL INFECTIONS
Superficial tinea infection of the palm and interdigital clefts (similar to athletes foot) is
fairly common and can be controlled by topical preparations
Tinea of the nails can be more difficult to eradicate and may require oral antifungal
mediction and complete removal of the nail.
NECROTIZING
FASCIITIS
NECROTIZING FASCIITIS
Necrotizing fasciitis is a true surgical emergency
60% of these cases are due to self-injection of substances into the upper extremities
Symptoms of necrotizing fasciitis may include pain out of proportion to examination,
violaceous bullae, cutaneous hemorrhage, skin sloughing, skin anaesthesia (late
finding), rapid progression, and gas in the tissue (crepitation)
Some cases may be polymicrobial, nevertheless: S pyogenes (group A streptococcus)
is the most common organism associated with this infection
Immediate surgical debridement is the definitive management in these cases
Adequate debridement is achieved by longitudinal incisions along the extremity and
debridement of all necrotic tissue including muscle, fascia, fat, and skin
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