HAND SPACE

INFECTIONS
Dr. Prendergast
OUTLINE
➤ Relative Anatomy
➤ Definition
➤ Incidence
➤ Aetiology
➤ Pathophysiology
➤ Types of Infections
o Presentation
o Treatment
o Complications
THE HAND
➤ Bones
➤ Muscles & Tendons
➤ Blood vessels
➤ Nerves
PATHOPHYSIOLOGY
➤ Usually a traumatic inoculation of
microorganisms (usually bacterial, but can also
be viral or fungal), but there can also be spread
from local compartments or haematogenously
➤ These microorganisms incite a local immune
response that leads to
➤ The release of cytokines
➤ The recruitment of immune cells such as
leukocytes (esp neutrophils)
➤ The immune response leads to the pillars of inflammation
➤ Tumor (swelling & oedema)
➤ Rubor (redness)
➤ Dolor (pain)
➤ Calor (fever)
➤ Functio Laesa (loss of function)
➤ Neutrophils engulf opsonized bacteria and form phagosomes into
which reactive oxygen species and hydrolytic enzymes are secreted

➤ Neutrophils also release enzymes which further incite the

inflammatory reaction
➤ During this inflammatory melting pot there is collection of protein
rich fluid, cellular debris and dead neutrophils, also known as pus.
The greenish colour derived from the presence of myeloperoxidase
(an enzyme within the neutrophils)
TYPE OF INFECTIONS
o Subcutaneous Abscess

o Paronychia

o Felon

o Septic Flexor Tenosynovitis

o Deep Space Infections
o Infections Secondary to: Human Bites
➤ Animal Bites
➤ Herpetic Whitlow
SUBCUTANEOUS ABSCESS
o H/o Puncture wound
o Oedema, Fluctuance +/- Cellulitis, erythema
o Microbiology: S. aureus most commonly
o Incise and Drain
o Antibiotics if clinically indicated
PARONYCHIA

o Abscess beneath the nail fold +/- between the nail

and matrix
o Occurs 2-5 days after minor trauma
o Risk factors: Manicures, Nail biting
o Microbiology: Mixed Aerobic & Anaerobic,
Aerobic / Anaerobic, Candida
PARONYCHIA

Acute
o Usually S. aureus
o Non-Surgical Mgmt: no abscess formation, minimal
inflammation
▪ Early Soaks (& Antibiotics)
▪ Warm water, burrow solution (aluminium acetate),
chlorhexidine, provodone-iodine, n/s
o Surgical Mmgt: Incise & Drain
PARONYCHIA
Chronic
o >6 weeks, Intermittent inflammation around the eponychium
o Microbiology: Mixed flora, Fungi common (C. albicans)
o Risk factors: Moist hands!!
o Treatment: Marsupialization & removal of the nail plate
o Topical steroids; Antifungal
COMPLICATIONS
o Progressive infection – felon, subcutaneous abscess
o Nail abnormalities
o Osteomyelitis
o Shortening of Phalanx
FELON

o Closed space infections of the volar pulp space

o Penetrating injury to the pulp space
o Severe throbbing pain, swelling, erythema
o S. aureus most common
o Treatment:
Early – Elevate, oral Antibiotics &
Warm soaks
▪ Late – I&D
➤ To prevent: pulp space necrosis,
osteomyelitis
▪ Incision: High Lateral / Mid Volar
▪ Pack Open and Soaks
SEPTIC FLEXOR TENOSYNOVITIS
o Bacterial infection of flexor sheath between visceral and parietal layer
o Occurs: Distal palmer crease to distal phalanx
▪ Thumb sheath contiguous with radial bursa
▪ Small finger sheath contiguous with ulnar bursa
▪ Both radial and ulnar bursa extend to the carpal tunnel
▪ Radial and ulna bursa communicate in over 50% of individuals-horseshoe
abscess
o NB – Risk of spread proximally
o Rapidly spreading bacterial infection within sheath as a result of penetrating trauma
o Staph Aureus most common organism
o Chronic, often indolent, infections may be due to atypical mycobacterium
SEPTIC
FLEXOR
TENOSYNO
VITIS

Kanavel’s Four Cardinal

Signs
Flexed posture of
affected digit
Tenderness along
flexor tendon sheath
Diffuse swelling
Pain with passive
extension
SEPTIC FLEXOR TENOSYNOVITIS
Treatment
o Very early cases: IV abx, splint, elevate
o Surgery
➤ Limited incision
➤ Extensile incision
➤ Irrigate – initial / continuous
o Institute mobilization with PT early
DEEP SPACE INFECTIONS
➤ Closed compartments of the hand
➤ Dorsal subaponeurotic space
➤ Thenar space
➤ Midpalmer space
➤ Hypothenar
➤ Interdigital subfascial web space
➤ Parona’s quadrilateral space
➤ These are prone to infection from penetrating trauma, local spread
and hematogenous dissemination
DORSAL SUBAPONEUROTIC

o Present as Dorsal hand swelling

o Incision: over second metacarpal and
space between fourth and fifth
o Never over extensor tendons
THENAR

o Contiguous spread from index

finger flexor tensosynovitis
o Can spread between aductor
pollicis and first dorsal
interosseus: pantaloon abscess
o Clinically: Thumb held in
abduction
MIDPALMAR

o Clincal
▪ Volar hand swelling
▪ Loss of normal palmar concavity
▪ Pain on passive movement of 3rd and 4th
digit
o Treatment - Surgically
▪ Transverse distal palmar incision,
oblique longitudinal incision, combined
▪ Wound either closed over irrigation
catheters or left open
HYPOTHENAR
o Less common
o Much less swelling
o No involvement of digits, flexor tendons
WEB

o Collar button abscess

o Subfascial infection
o Usually starts volarly and forced
dorsally through lumbricals
o Presentations: volar and dorsal web
swelling
o Incision: Volar and dorsal incisions
SPACE OF PARONA
o Boundaries: Pronator quadratus, Flexor tendons
o Presentation
▪ Pain on finger flexion
▪ Carpal tunnel syndrome
HUMAN BITES
o Typically Clenched Fist injuries from punch to mouth
▪ Risk of extensor tendon injury or open fracture
o True Bite wounds
o Over 40 different strains of bacteria
o May seem innocuous due to multiple planes of injury that alter alignment in different hand
positions
o Wound over MCP should be considered intraarticular (MCPJ) until proven otherwise to
avoid potential consequences of untreated septic arthritis
▪ Highly prone to infection due to proximity of skin over knuckles to joint capsule
➤ Polymicrobial
➤ S pyogenes, S aureus, Group A streptococcus
➤ Eikenella corrrodens (oral flora) 7-29%
➤ Viruses
ANIMAL BITES
o Dogs> cats > rodents
o Risk of infection:
▪ Dog bites: 4%
➢ Crushing tearing mechanism with blunt teeth
▪ Cat bites: 50%
➢ Sharp piercing teeth causing small break in skin that heals quickly trapping bacteria

o Pasteurella multocida very common along with Staph, Strep and

anaerobes, Bartonella (cat scratch disease)
TREATMENT
o Should be explored for tendon injury, open joint injury in both
anatomical and clenched fist position
o Debridement, irrigation
o Antibiotic coverage including penicillin, ampicillin for Eikenella
o Tetanus prophylaxis, Hepatitis B prophylaxis
 HERPETIC
WHITLOW

Herpes simplex
infection involving
the hand
Clear vesicles
mature, unroof and
leave ulcerated base
Ulcer subsides over
the ensuing weeks
HAND INFECTIONS IN JAMAICA

➤ Mansingh & Sawh WIMJ ’01

o Staph. aureus predominates (60%)
o Strep. common
o Bites may have multiple organisms (anaerobes, Eikenella ssp.)
o GNB common in
➤ systemic disease eg diabetes, renal failure
➤ wood related injuries
o Organisms in Jamaica not yet resistant
o Cloxacillin, Augmentin®, Cephalosporin usu. effective for most infections
o Add aminoglycoside if high risk
PRESENTATION
➤ History: chronic illnesses, history of trauma, c/o pain and swelling
➤ Physical examination: erythema, warmth, fluctuant and tender
swelling, painful ROM
➤ Kanavel’s Sign:
➤ Finger held in slight flexion
➤ Fusiform swelling
➤ Tenderness along flexor tendon sheath
➤ Pain with passive extension of the sheath
TREATMENT