East Avenue Medical Center

Department of Orthopedics

HAND
ABSCESS
Presented by:
Kris Pauline Carlos
Gisselle Marie Chan
Nikki Diocampo
Sharde Mae Garcia
OBJECTIVES
GENERAL
- To present a case of R. P. , a 16 years old male, left handed
with a right hand pain and swelling
OBJECTIVES
SPECIFIC
- To present a thorough history and physical examination
- To discuss the anatomy of the hand
- To discuss an overview of common acute hand infections
- To discuss patient evaluation and treatment principles of
Collar-Button Abscess
 IDENTIFYING DATA
R.P Presently residing at
16 years old Quezon city
Male Admitted for the 1st time at
Left-handed East Avenue Medical
Filipino Center on July 16, 2019 at
Roman Catholic 11 p.m
Grade 10 Under the service of
Orthopedics department
 CHIEF COMPLAINT
Pain and swelling of the right hand

INFORMANT & % RELIABILITY

Patient, 90% reliability
 HISTORY OF PRESENT ILLNESS
3 weeks PTA
noted multiple
pruritic,erythematous papules on In the interim
the 1st web space of the right hand -Patient noted
excoriations to
Due to persistent scratching, resolve
multiple excoriatations were noted spontaneously
on the site of lesion -No trauma noted at
NO CONSULT; NO MEDS TAKEN the right hand
PX TOLERATED THE CONDITION
 HISTORY OF PRESENT ILLNESS
5 days PTA
-noted swelling over his 1st web space volar aspect of the
right hand
-with associated:
• bullae containing yellow pus
• redness
• pain, sharp, non-radiating, PS: 8/10, upon movement
-no fever
NOand history of trauma noted
CONSULT
AMOXICILLIN 500 mg TID, taken for only 1 day and
MEFENAMIC ACID 500mg OD, taken for 4 days
PX TOLERATED THE CONDITION
 HISTORY OF PRESENT ILLNESS
5 days PTA 4 days PTA
-swelling -base of the R. thumb
-bullae with yellowish -increasing in size
pus
-base of the R. thumb
-redness
-radiating to the R. wrist PS: 10/10,
-pain, sharp, non-
radiating, PS: 8/10, upon upon rest and movement
movement -noted difficulty in thumb movement
-with fever, intermittent, Tmax-(X), no
meds
-no fever
-no trauma
-no consult
-took Mefenamic acid 500 mg OD for
 HISTORY OF PRESENT ILLNESS
5 days PTA 4 days PTA 1 day PTA
-swelling -base of R.thumb
-bullae -size increases
-redness -base of R. thumb
-pain, non-radiating, PS: -radiate to R. wrist PS: 10/10, -radiate
8/10, upon movement upon rest and mov’t
ventral
-limited R. thumb ROM R.forearm
-no fever -fever, intermittent, Tmax-undocu,
-no trauma
-no consult
-Amoxicillin & -Mefenamic acid; D/C
Mefenamic acid Amox
 HISTORY OF PRESENT ILLNESS
5 days PTA 4 days PTA 1 day PTA
-swelling -base of R.thumb A
-bullae -size increases D
-redness -base of R. thumb -radiate M
-pain, non-radiating, PS: -radiate R.wrist - ventral I
8/10, upon movement
limited R. thumb R.forearm S
ROM S
-no fever
-fever, intermittent, Tmax- I
-no trauma undocu,
-no consult O
-Amoxicillin & N
Mefenamic acid -Mefenamic acid;
 PAST MEDICAL HISTORY

no previous hospitalizations

no previous surgeries
no known comorbidities such as asthma, diabetes mellitus,
hypertension
no history of infectious disease such as TB, pneumonia
no allergies to food and medications
no other members of the family has the same condition as
the patient
 FAMILY HISTORY

 Type 2 Diabetes Mellitus on the paternal side

 No other known heredofamilial diseases such as
hypertension, asthma, cancer
 PERSONAL-SOCIAL HISTORY

Patient smokes 0.4 pack years

 Patient drinks 3-4 bottles of 350 ml, 65 proof Rhum shared
among friends, approximately 2x/week for 4 yrs now
 Patient denies of illicit drug use
 REVIEW OF SYSTEMS
GENERAL (+) for fever, loss of sleep; (-) for weight loss, weakness,
loss of appetite,
HEENT (-) for headache, dizziness, blurring of vision, epistaxis, gum
bleeding, pain upon swallowing
NECK (-) for stiffness, pain
RESPI (-) for difficulty in breathing, shortness of breath, cough
CARDIAC (-) for chest pain, dyspnea, hypertension, palpitation
URINARY (-) for increased frequency, dysuria, hematuria
GENITAL (-) for testicular enlargement, pain and penile discharges
PERIPHERAL (-) for intermittent claudication, cramps, edema
VASCULAR
 REVIEW OF SYSTEMS
HEMATOLOGIC (-) for easy bruising, bleeding
NEUROLOGIC (-) for tremors, seizures, changes in mood and
orientation
ENDOCRINE (-) for heat and cold intolerance, polyphagic,
polydipsia, polyuria
PSYCHIATRIC (-) for nervousness, memory changes and suicidal
attempt
 PHYSICAL EXAMINATION
 GENERAL SURVEY: conscious, coherent, well-nourished,
ambulatory, not in respiratory distress
 VITAL SIGNS: BP-110/70 mmHg, PR-90 bpm, RR-20 cpm,
T- 36.6 C, O2 sat- not measured
 EXTRIMITIES:
RIGHT HAND
• slight deviation to the normal hand posture
• erythema over the volar aspect of the 1st web space extending
to the thenar area and middle ventral aspect of the forearm
• (+) papular scars and excoriations, more prominent near the
thumb
 PHYSICAL EXAMINATION
RIGHT HAND
• (+) subcutaneous abscess formation on the 1st web space to
the base of the thumb
• (+) swelling over the 1st web space of the volar aspect
• thumb in wide abduction
• (+) warm to touch
• (+) tenderness at the 1st web space of the volar aspect and
ventral aspect of the forearm
• intact ROM of the fingers
• 80 deg flexion and 80 deg extension of the wrist
• 70 deg radioulnar deviation
 PHYSICAL EXAMINATION
RIGHT HAND
• (+) full flexion and extension of the IP joint of the thumb
• limited flexion and adduction of the thumb
• (+) inability to do thumb opposition
• Intact 2 pt discrimination at 5 mm on the ventral surface of the
thumb
• Intact sensation on the lateral aspect of the little finger, lateral
aspect of the middle finger and 1st web space of the hand
• good and strong radial and ulnar pulses
• CRT < 2 sec
 ADMITTING IMPRESSION

THENAR ABSCESS,
RIGHT
 HAND POSTURE
COMPLETLEY RELAX WITH FOREARM SUPINATED

-weight of hand causes the wrist to fall into some 30 deg of

dorsiflexion
-metacrpophalangeal joints lie in increasing flexion:
40 deg in the index finger
50 deg in middle finger
60 deg in ring finer
70 deg in small finger
-”cascade”: the distance from the digital pulp to the palmar
crease decreases in smooth progression from the index to the
 HAND POSTURE

UNSUPPORTED, RELAX ARM IS TURNED INTO

PRONATION

-wrist falls into 40-70 deg of palmar flexion, depending

on whether the elbow is extended or flexed
-fingers and thumb all extend:
thumb fully extend
finger joint to within 20 deg of the neutral position
 HAND POSTURE

POSTURE IN THE RELAXED HAND

-determined by the balance between the resting tone in

the flexor and extensor tendons
-”tenodesis effect”: mechanism by which the posture of
one joint is influenced by that of another
 INSPECTION OF HAND

•Skin
•discoloration
•trophic changes (i.e. increased hair growth or
altered sweat production)
•can represent derangement of sympathetic
nervous system
•scars/wounds
 INSPECTION OF HAND
•Swelling
•Muscle atrophy
•thenar atrophy
•median nerve involvement
•caused by carpal tunnel syndrome
•interossei atrophy
•ulnar nerve involvement
•caused by cubital tunnel or cervical radiculopathy
•subcutaneous atrophy
•locally post-steroid injection
 INSPECTION OF HAND
Deformity
•asymmetry
•angulation
•rotation
•absence of normal anatomy (previous amputation)
•cascade sign
 PALPATION OF HAND
Masses (ganglions, nodules)
Temperature
warm: infection, inflammation
cool: vascular pathology
Tenderness
Crepitus (fracture)
Clicking or snapping (tendonitis)
Joint effusion (infection, inflammation, trauma)
 RANGE OF MOTION OF THE HAND
FINGER
MCP: 0 deg extension to 85 deg of flexion
PIP: 0 deg extension to 110 deg of flexion
DIP: 0 deg extension to 65 deg of flexion

WRIST
60 deg flexion
60 deg extension
50 deg radioulnar devation
 RANGE OF MOTION OF THUMB
FLEXION: move thumb across palm and touch base of the
5th finger
EXTENSION: move thumb back across and away from
fingers
ABDUCTION: palm up, thumb neutral, move thumb away
from palm
ADDUCTION: palm up, thumb neutral, move thumb back
OPPOSITION: (movements of thumb across the palm)
have patient touch thumb to each fingertip
NEUROVASCULAR EXAM OF THE HAND
SENSATION
Two-point discrimination
-used to test sensory innervation of the digits
-normal values:
thumb:2.5-5mm
index: 3-5 mm
other digits: 4-6 mm
base of the palmar aspect of the digit: 5-6 mm
thenar and hypothenar eminence: 5-9 mm
dorsal aspect of digit: 6-9 mm
dorsal aspect of hand: 7-12 mm
NEUROVASCULAR EXAM OF THE HAND
MOTOR
Radial nerve: test thumb IP joint extension against
resistance
Median nerve:
recurrent motor branch: palmar abduction of the
thumb
anterior interosseous branch: flexion of thumb IP
and index DIP (“A-OK sign”)
Ulnar nerve: cross-fingers or abduct fingers against
resistance
NEUROVASCULAR EXAM OF THE HAND
VASCULAR
Radial pulse
Ulnar pulse
Allen’s test
Capillary refill
CASE DISCUSSION
ANATOMY
 BONES

• Carpal bones (8)

• Matacarpals (5)
• Phalanges (14)
MUSCLES

• Intrinsic
– Palmar brevis
– Interossei
– Adductor pollicis
– Thenar
– Hypothenar
– Lumbrical muscles
MUSCLES

• Intrinsic
– Palmar brevis
– Interossei
– Adductor pollicis
– Thenar
– Hypothenar
– Lumbrical muscles
MUSCLES

• Intrinsic
– Palmar brevis
– Interossei
– Adductor pollicis
– Thenar
– Hypothenar
– Lumbrical muscles
MUSCLES

• Intrinsic
– Palmar brevis
– Interossei
– Adductor pollicis
– Thenar
– Hypothenar
– Lumbrical muscles
MUSCLES

• Intrinsic
– Palmar brevis
– Interossei
– Adductor pollicis
– Thenar
– Hypothenar
– Lumbrical muscles
VASCULAR
SUPPLY
VASCULAR
SUPPLY
NERVES
NERVES
NERVES
PARONYCHIA

• Acute Paronychia
– Most common infection of the hand
– Involves soft tissue fold around the fingernail
PARONYCHIA

• Acute Paronychia
– Usu. results from bacterial inoculation of
the paronychia tissue by a sliver of nail or
hangnail, by a manicure instrument, or
thru nail biting
• Disruption of barrier bet nail fold and nail
plate >> introduction of bacteria into the
tissue borders of the nail
PARONYCHIA

• Most common infecting organisms:

– Staphylococcus aureus
PARONYCHIA

• Clinical Presentation:
– Hallmark:
• (+) erythema, swelling, and tenderness
immediately adjacent to the nail
PARONYCHIA

• Chronic Paronychia
– characterized b y chronically indurated and rounded eponychium
– Chronic inflammation + repeated episodes of inflammation and drainage
PARONYCHIA

• Chronic Paronychia
– More common in:
• Middle aged women, with a female-to-male ratio of 4:1
• Housewives
• Bartenders
• dishwashers

– Predisposing condition:
• Frequent water immersion,
– Particularly in detergents and alkali solutions
PARONYCHIA

• Chronic Paronychia
– Cultured organisms:
• Gram-positive cocci
• Gram negative rods
• Candida
• Mycobacterial species
FELON

• From the Latin word fel, meaning “bile” or

“venom”
• A subcutaneous abscess of the distal pulp
of a finger or thumb
• involves multiple septal compartment
syndrome of the distal phalangeal pulp
FELON

• Clinical Presentation
– accounts for 15% to 20% of all hand
infections
– Characterized by severe pain, tension, and
swelling of the entire distal phalangeal pulp
– Swelling DOES NOT extend proximal to the
DIP crease
– (+) compromised venous return >>
microvascular injury >> necrosis and abscess
formation
FELON

• Clinical Presentation
– Often (+) hx of penetrating injury
preceding a felon
• E.g. diabetics’ fingertips for blood tests
– Expanding abscess >> may extend toward
phalanx >> osteitis/osteomyelitis
FELON

• Most commonly cultured organisms from felons:

– S. aureus

– Others:
• Gram negative bacteria (though uncommon and usually seen in diabetics and immunocompromised
patients)
FELON

• Apical infections
– Superficial infections of the most distal part of the pulp skin
– Distinction from felon:
• Palmar pad is not involved
PYOGENIC FLEXOR TENOSYNOVITIS

• Is a closed-space infection of the flexor tendon sheath of the fingers or thumb

• Purulence within the tendon sheath >> destruction of the tendon gliding mechanism >>
adhesions >> severe loss of motion
• May destroy blood supply >> tendon necrosis
PYOGENIC FLEXOR TENOSYNOVITIS

• Most common organism:

– S. aureus and β-hemolytic Streptococcus
PYOGENIC FLEXOR TENOSYNOVITIS

• Most patients have (+) hx of penetrating trauma

over the volar aspect of the PIP or DIP joint.
• Cardinal signs:
– Semiflexed position of the finger
– Symmetric enlargement of the whole digit
– Excessive tenderness limited to the course of the
fexor tendon sheath
– Excruciating pain on passively extending the finger
RADIAL AND ULNAR BURSAL AND PARONA
SPACE INFECTIONS
• more commonly associated with flexor tendon sheath infections (septic flexor tenosynovitis) of
the small finger or thumb
RADIAL AND ULNAR BURSAL AND PARONA
SPACE INFECTIONS
• Radial bursa
– Is a continuation of the tendon sheath of
the flexor pollicis longus (FPL) tendon.

• Ulnar Bursa
– begins at the proximal end of the small
finger flexor tendon sheath
– widens more proximally, overlapping the
mid fourth metacarpal and the proximal
base of the third and fourth metacarpals
RADIAL AND ULNAR BURSAL AND PARONA
SPACE INFECTIONS
• Parona Space
– is the deep potential space in
the distal volar forearm.
RADIAL AND ULNAR BURSAL AND PARONA
SPACE INFECTIONS
• most useful in diagnosing early disease:
– Pain with palpation along the flexor tendon sheath and pain with passive extension

• most valuable sign of ulnar bursal infection

– (+) tenderness at the junction of the distal flexion crease of the wrist and the hypothenar
eminence
• most valuable sign for radial bursal infections
• tenderness at the junction of the distal wrist flexion crease and the thenar eminence
SEPTIC ARTHRITIS

• Characterized by presence of a purulent exudate within the closed confines of a joint

• (+) swelling, redness, warmth, and pain around the affected joint
• Most common organisms:
– S. areus and streptococcal species
SEPTIC ARTHRITIS

• Toxins from bacteria >> immunogenic response >> destrction of the hyaline cartilage and
increase pressure in joints
SEPTIC ARTHRITIS

• Characterized by presence of a purulent exudate within the closed confines of a joint

• (+) swelling, redness, warmth, and pain around the affected joint
• Most common organisms:
– S. aureus and streptococcal species
OSTEOMYELITIS

• An infection of the bone

• Represent 1% to 6% of all infections
• Most commonly involved bone:
– Distal phlanx
OSTEOMYELITIS

• May occur after:

– Penetrating trauma (most common cause)
– Crush injuries
– Contiguous spread from adjacent soft tissue infections; or
– Hematogenous seeding
HAND
INFECTIONS
❌ Antibiotic therapy
Location
❌ Surgical treatment
Infecting organism
Timing of treatment
Adequacy of surgical drainage
Efficacy of antibiotics
Host  Malnutrition
 Aloholism
 Autoimmune diseases
 Chronic Corticosteroid use
Disabilities  Hepatitis
 HIV
 Stiffness  DM
 Contracture
 Amputation
PATIENT EVALUATION
Thorough medical history to assess risk factors
Tetanus Immunization status
Prime features of hand infection:
 Pain (dolor)
 Increased Temp (calor)
 Erythema (rubor)
 Tenderness
Labs: CBC, CRP, ESR, Electrolytes, RBG, Culture
Radiographs: foreign body, gas within soft tissues, fracture,
septic joint, osteomyelitis
Aspiration/Decompression, Debridement
Medications: NSAIDS and/ Antibiotics
TREATMENT PRINCIPLES
Surgical Setup and Incision
 Tourniquet control
 Elevation (not elastic) to exsanguinate the limb
 Surgical incisions long and extensile
 Planned to minimize exposure of blood vessels, nerves, ten
dons
 Avoid longitudinal incisions across flexion creases

Debridement
 Excision of all necrotic tissue

Specimens
 GSCS
TREATMENT PRINCIPLES
Irrigation
 Copious irrigation to reduce bacterial load

Wound Management
 Left open
 Negative-pressure dressings
 Do not be overly eager for immediate wound closure
 Delayed primary wound closure/ healing by secondary intent
ion
TREATMENT PRINCIPLES
Postoperative care
 Frequent dressing change
 Early motion
 Multiple debridement to eradicate infection
 Empirical antibiotic therapy
 Infectious disease consultation
 COMMON HAND INFECTIONS

Radial and Ulnar

Wrist Joint
Paronychia Bursal and Parona
Infections
Space Infections
Septic Boutonnière
Deep Space
Felon and Mallet
Infections
Deformity
Pyogenic Flexor
Septic Arthritis Osteomyelitis
Tenosynovitis
 COMMON HAND INFECTIONS

Radial and Ulnar

Wrist Joint
Paronychia Bursal and Parona
Infections
Space Infections
Septic Boutonnière
Deep Space
Felon and Mallet
Infections
Deformity
Pyogenic Flexor
Septic Arthritis Osteomyelitis
Tenosynovitis
 Deep Spaces

Deep Subfacial
Palmar Spaces
Spaces

Hypothena
Thenar Midpalmar
r
 Deep Spaces

Deep Subfacial
Palmar Spaces
Spaces

Hypothena
Thenar Midpalmar
r
 Hypothena
Thenar Midpalmar
r
 Deep Space
Infections

Deep Subfacial
Palmar Space
Spaces

Dorsal Dorsal
Hypothena Interdigital
Thenar Midpalmar Subcutaneou Suaponeuroti
r Web Space
s c
Interdigital
Web Space
Interdigital
Web Space Pertinent Anatomy
- loose areolar connective tissue between the
metacarpal heads and around the deep
intermetacarpal ligament
- Infection most commonly begins on volar
surface
- Strong attachments of palmar fascia to the skin
limit volar extension of the abscess
Interdigital Web
Space
Abscess “Collar-Button Abscess”
- hourglass shape abscess
- Etiology:
• fissure in the skin between the fingers
• distal palmar callus
• infection in subcutaneous area of proximal segment of a
finger
- localized pain and swelling
- adjacent fingers lie abducted from each other
Incisions for web space abscesses

Curved Volar Volar

Dorsal
longitudinal Zigzag Transverse
Incision
incision Approach Approach
Incisions for web space abscesses
Preferred incision
 Excellent abscess
exposure
 Reduced risk of skin
edge necrosis
 Easier access

Curved
Dorsal
longitudinal
Incision
incision
Incisions for web space abscesses

Volar
Zigzag
Approach
Incisions for web space abscesses

Volar
Transverse
Approach
R. P. 16/M
“Collar-Button Abscess”
POSTOPERATIVE MANAGEMENT
- Wounds are left open
- Wet gauze sponge – bulky dressing
- Hand elevated
- IV antibiotics continued for 14 to 21 days then oral
antibiotics continued to complete 4-week course of therapy
- First dressing change done at 12 to 24 hours
- Begin soaking in a dilute povidone-iodine solution
- Early motion initiated
COMPLICATIONS
- Stiffness and contracture
- Extensor lag
- Skin necrosis
- Tendon necrosis
- Painful scar formation
- Nerve injury
PROGNOSIS
- 70% to 80% of patients achieve full recovery
CRITICAL POINTS
Etiology Penetrating Injury is the most common source of infection

Preoperative Clinical Examination

Evaluation Radiographs to evaluate for foreign body or fracture
MRI is very helpful in identifying localized abscess

Pearls Thenar space infections Wide thumb abduction and difficulty with opposition
Midpalmar space infectionsLoss of palmar concavity and fingers are semiflexed
Collar-button abscess Abduction of adjacent fingers
 CRITICAL POINTS
Pitfalls Delayed surgical treatment
Inadequate decompression
Injury to neurovascular structures

Postperative IV antibiotics
Care Pain management
First dressing change between 8 and 12 hours
Soaks in dilute povidone-iodine solution three times per day
Repeat débridement and irrigation in 48 hours if symptoms not improving
THANK YOU! 