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DR.ISLAM MAGDY SALIM
Resident of general surgery
Kafer Eldwar general hospital
Hand spaces the the the the the superficial pulp spaces of the fingers. radial bursa. thenar space. ulnar bursa. . midpalmar space.
which is periosteum. Each pulp space is subdivided by the presence of numerous septa.Pulp Space of the Fingers The deep fascia of the pulp of each finger fuses with the periosteum of the terminal phalanx just distal to the insertion of the long flexor tendons and closes off a fascial compartment known as the pulp space . The epiphysis of the distal phalanx receives its blood supply proximal to the pulp space . filled with fat. Through the pulp space. runs the terminal branch of the digital artery that supplies the diaphysis of the terminal phalanx. which pass from the deep fascia to the periosteum.
The thenar space contains the first lumbrical muscle and lies posterior to the long flexor tendons to the index finger and in front of the adductor pollicis muscle .
The midpalmar space contains the second. third. and fifth metacarpal bones . fourth. and little fingers. ring. and the third. It lies in front of the interossei fingers. and fourth lumbrical muscles and lies posterior to the long flexor tendons to the middle.
.The radial bursa is a continuation of the flexor pollicis longus tendon sheath through the flexor retinaculum to a level 2. joint.5 cm above the wrist joint.
wrist. It too passes through the flexor retinaculum to end 2. .5 cm above the wrist. wrist.The ulna bursa arises from the sheath of the fifth digit and joins the common flexor sheath at the wrist.
PARONA'S SPACE This is a non-synovial-lined space on the non-synovialflexor side of the wrist located between the flexor tendons and the pronator quadratus muscle. It is bounded radially by the flexor carpi radialis and ulnarly by the flexor carpi ulnaris and antebrachial fascia. muscle. . fascia.
Types of hand infection .
. herpetic whitlow. splinters or foreign body. pyogenic granuloma.Acute Paronychia Definition : Paronychia is an infection that develops along the lateral nail fold of the fingernail or toenail. In the very early stage. Complication : complications of a neglected paronychia such as felon. it begin with cellulitis of the lateral nail fold. Physical examination : localized pain and swelling surrounding the nail Differential diagnosis : mucous cyst. less than 24 hours. tenosynovitis of flexor tendon should be considered. It is predominant in all ages and more common in females than in males. In the US. paroychia is the most common hand infection. staphylococcus Aureus History : It may arise spontaneously. sarcuma. osteomyelitis is suspected or to rule out xforeign body. Kaposi sarcuma. subungual fibroma. Bowen disease. osteomyelitis. with a female to male ratio of 3:1 of Causes : Paronychia are most often caused by common skin bacteria . Laboratory studies : aerobic and anaerobic cultures Imaging studies : an x-ray should be considered if the patient has a history of recent finger trauma. or following trauma of the nail bed. glomus tumor. malignant melanoma and squamous cell carcinoma.
.2 Single incision with or without partial nail removal . Conservative treatment : if the patient come with cellulitis and the problem is diagnosed within the first 24 to 48 hours after onset. A more aggressive more approach can be performed by separated incision with blade no. Blunt separation should be carried no. gauge needle or blade no.11 proximally to open the eponychial cul de sac if there is any collection of pus. -Deep abscess In larger. double incisions can be performed to elevate the entire eponychium and excised proximal portion of the nail. with or without partial nail removal If there is minimal swelling with cellulitis. If it is necessary .11 to separate the cuticle of the lateral nail fold to rule out or drain the pus. The Freer elevator or straight hemostat can be use to elevate portion of nail adjacent to paronychia and one fourth of nail is cut with scissors in order to decompress the paronychium and facilitate drainage.11 2. Surgical treatment 2. more redness and swelling that is not superficial abscess and dose not allow drainage after partial nail removal. 2. a non adherent gauze dressing is required to prevent premature closure of the cavity.Superficial abscess If the abscess is very superficial or there is insensitive distended epithelium.11 in the nail fold. A tiny wick may be packed to ensure drainage.Treatment 1. gently use a Freer elevator. the pus beneath the proximal part of the nail that requires removal of proximal one third of the nail.11 Partial nail removal may be performed if it facilitate and ensure drainage. an 18 Freer elevator. no incision.3 Proximal nail removal with or without incision in subungual abscess If the infection extend from lateral nail fold to involve entire eponychium known as eponychia. The Freer elevator is use to gently separate the cuticle of the eponychium from the underlying nail and then the straight hemostat is required to pull the proximal portion of the nail out from under the eponychium and than proximal one third of the nail is excised with scissors. the paronychia can be treated by conservative treatment 2.1 Separation. the incision can be carried out at this point with blade no. After the pus is removed and the cavity is irrigated.11 point with no. no. There is usually collection of eponychia.
Differential diagnosis : -pyogenic flexor tenosynvitis Complication : -skin necrosis -osteomyelitis -septic arthritis -pyogenic flexor tenosynovitis Laboratory studies : aerobic and anaerobic cultures Imaging studies : an X-ray should be considered to rule out retained foreign material or osteomyelitis. erythematous of the finger pulp.Felon(pulp space infection) Definition : A felon is a subcutaneous abscess in a closed space of the pulp of a finger or thumb. In the US.In the early stag . particularly in X- to cure a felon or failure immunocompromised patients.Edematous. the infection begin with cellulitis and may have tight or prickling pain. Physical examination : . marked throbbing pain and tender to palpation -Occasionally. . however. there is extension of the infection via lymphatic system with swollen lymph glands behind the elbow and in armpit armpit -It is possible to develop a fever with a felon (3). felons and paronychias account for approximately one third of all hand infections. minor cut or wooden splinter. . Thumb and index finger are the most commonly affected digits Causes : Felons are usually caused by Staphylococcus aureus History : -The felon is often a consequence of minor trauma such as a needle puncture. there is no history of injury over one half of patients. -The felon may spread from a paronychia.
482. then the cavity is irrigated and packed with a plain gauze wick for 48-72 hours. 11. the cavity is packed with plain gauze wick for 48-72 hours. -This patient may need systemic intravenous antibiotics and X-ray should be considered to rule out osteomyelitis of the distal phalanx. 0. Longitudinal volar incision -If the most fluctuation point or a draining sinus is located at the mid volar aspect of the pulp. 48-It is important to facilitate adequate drainage by separation or division of the fibrous septa. it may resolve spontaneously. 1. Unilateral longitudinal incision -If there is no most fluctuation point or a draining sinus. the lateral skin incision should be performed on the ulnar side of index. into -Transverse skin incision may cause ischemia or anesthesia by injury to neurovascular bundle. . Xphalanx. distal to the DIP joint flexion of crease and not go to the fingertip. Surgical treatment Surgical drainage should be indicated in an established felon that an abscess is already formed. -Through and through gauze wick is placed for 48 72 hours. -At early stage of this infection with cellulitis. blunt instrument is used to evacuate pus and separate septa from the periosteum of the phalanx. -For an incision. -The incision should not cross the DIP joint flexion crease to prevent flexion contracture and avoid extension of infection into flexor sheath. 11. -After skin incision has been performed. -It is rarely needed and may be indicated in severe infection that adequate drainage can not be achieved by unilateral incision (4).Bilateral longitudinal incision -The longitudinal incision can be performed on both sides of the digit. middle and ring finger.Treatment Conservative treatment -There is no conservative treatment in an established felon that an abscess is already formed. The blunt instrument is used to separate the fibrous septa from the periosteum of the phalanx. but on the radial side of the thumb and small finger. the incision can be carried out longitudinally at this point with blade no. -After irrigation. 3.5 cm. particularly with antibiotics. the incision can be carried out longitudinally at lateral aspect of the midlateral line .
aureus. space infection in the flexor tendon sheath of the digit.Pyogenic Flexor Tenosynovitis Definition : Pyogenic flexor tenosynovitis is a closed are the most frequently involved digits. herpetic whitlow and inflammatory flexor tenosynovitis. Imaging studies -an x-ray should be considered to rule out phalangeal fracture. History : -Infection can be introduced directly into the tendon sheaths though the skin wound such as penetrating trauma or via hematogenous spreading. gout. Differential diagnosis -phalangenal fracture. (3) excessive tenderness over the course of the sheath but limited to the sheath. The most common organism is S. -pyogenic flexor tenosynovitis can be the complication of the felon and can extend to other deep space infections of the hand. x- . there was hematogenous seeding to four flexor tendon sheaths (5). Complication -tendon necrosis and rupture -osteomyelitis -septic arthritis -horseshoe abscess from communication with Parona s space of the wrist -thenar space abscess from rupture of pyogenic flexor tenosynovitis of index finger -midpalmar space abscess from rupture of pyogenic flexor tenosynovitis of middle and ring fingers -stiffness Laboratory studies -aerobic and anaerobic cultures -WBC count. The latter may be the first sign present early in the process. In one study. middle and ring fingers middle Causes : Most of the organisms isolated from pus cultures were common flora of the skin and mouth such as Staphylococcus and Streptococcus species. (2) symmetric enlargement of the whole finger. arthritis. Physical examination -Kanavel (6) originally described the four cardinal signs of flexor tenosynovitis : (1) a flexed position of the finger. bony involvement and foreign body.ESR. partial treatment of antibiotics and immunocompromised patient. -Pyogenic flexor tenosynovitis can develop as early as 6 hours after the initial penetrating wound.ESR. The index. count. and (4) excruciating pain with passive finger (3 (4 extension.aureus. -Kanavel cardinal signs may be incomplete or absent in patients with early stage of infection. -coagulation studies in severe infection with sepsis. S.
5 5 French feeding tube is inserted under the A1 pulley for a distance of 2 cm. 2. in the thumb and small finger. pulleys and sheath. patients who are immunocompromised or have diabetes.Open drainage and debridement If there are necrosis of the flexor tendon. the A1 pulley sheath and tendon are visualized. transverse . Additionally. The patency of the system is checked before the hand is dressed and splinted. Surgical treatment The surgical drainage should be undertaken when (1) It fail to improve after conservative treatment. a midaxial incision is preferred and made on the ulnar side of index. open drainage should be undertaken. The proximal incision. closed irrigation technique should be considered. For postoperative irrigation program. First incision made over A1 pulley to incision A1 identify necrosis of sheath and drain pus from the cul de sac. early surgical intervention is warranted. the radial side is preferred. If there A1 are no necrosis. if there are necrosis. (2) patient is seen more than 48 hours after onset. it can be treated by conservative treatment. There are two incision needed. If the improvement is in doubt. For distal incision. After the pus is drained . warm water soaks or whirlpool treatment is initiated. Some connect 25the catheter to a 50 ml syringe and the sheath is flushed manually with 5 ml of NSS every hour. open drainage and debridement are indicated. distal incision is made over the region of A5 pulley. Second incision is made at the digit. vertical or zigzag . . pulleys or sheath . compressive dressing and splint are removed. additional irrigation for 24 hours may be continued. a 16 gauge polyethylene catheter or # 3.Treatment Conservative treatment If the patient is presented within 24 48 hours of the onset of infection. middle and ring finger A5 . There are two incision needed for this technique proximal and distal incision. through A1 the proximal or separated incision. The irrigation program is usually continued for 24 48 hours. Midaxial incision is preferred because zigzag incision may complicate closure if there is skin necrosis.Closed irrigation If there are no necrosis of the flexor tendon. After proximal and distal incision were made. A small drains is placed in the distal incision and the wound may left open or be closed distal around the drain. The tendon sheath is irrigated until the fluid is clear. is made over the A1 pulley of the finger or A1 over the thenar crease of the thumb. Approximately 48 hours often surgery. continuous irrigation with NSS at 25 ml/h or intermittent irrigation every 2-4 hours with 25-50 ml of NSS are equally effective. Operative method 1.
grossly swollen of thenar eminence .flexed and abducted resting posture of the thumb .Thenar space infection .pain with passive adduction .marked swelling of thumb-index web thumbspace .
Treatment Surgical drainage and debridement can be performed over the point of greatest tenderness through a curved incision in the web between the thumb and index finger . performed. combined dorsal and volar approach can be performed. -Closed irrigation technique can be performed .The incision can be done along the thenar crease in the palm -If it is necessary.
limitation and pain with movement of the middle and ring fingers .pain and swelling in the central palm .loss of palmar concavity .swelling of the hand .Midpalmar space infection .
performed. -Another skin incision can be made along the ulnar border of the hand between the fifth metacarpal and the hypothenar muscle. . -Closed irrigation technique can be performed. muscle. maximal.treatment The surgical drainage can be performed by making a transverse incision in the middle third of the palmar crease or wherever fluctuation is maximal.
. (3) across the finger into an adjacent web space. finger.The infection may spread 1. the fingers on either side of the web separate from each other . space. -The point of maximum tenderness is on the palmar surface of the web. space. posteriorly towards the dorsum caused double abscess configuration. (2) along a lumbrical canal into the midpalmar space. space. -If infection is severe.Interdigital web space infection -pain and swelling localized to the web space. (4) distally into the finger. web. configuration.
arteries. . -Blunt dissection is used to establish the communication between the two incisions and protect the digital nerves and arteries.treatment Surgical incisions are usually performed both on the dorsal and palmar aspect of the infected web space. side. space. used. -A curved or zigzag incision is made on the palmar surface -A longitudinal incision is made between the base of finger on the dorsal side. -The superficial transverse metacarpal ligament and other fibers may be divided to allow better exposure. -Closed irrigation technique may be used. exposure.
-bizarre parosteal osteochondromatous proliferation (BPOP) -acrometastases of malignant tumor -neuropathic artheopathy -Osteosarcoma of distal radius had been treated as osteomyelitis(16) . probe to bone test may be used to evaluate the possibility of osteomyelitis by insertion of sterile blunt insertion probe into ulcerated lesion. Pain film radiography and bone cultures are the mainstays of diagnosis.develops within two weeks after disease onset . CT. Patient usually present within several days to one week after the onset of symptoms with tenderness over the involved bone and decrease tenderness ROM in adjacent joints. Differential diagnosis.Osteomyelitis Definition : Osteomyelitis is an inflammation of bone caused by a pyogenic organism. the osteomyelitis may be suggested. Patient usually present with draining sinus tracts. MRI and ultrasound examination are used when diagnosis ultrasound of osteomyelitis is equivocal or to help in determination of the extension of bone and soft tissue infection. Imaging with radionuclide scans. fugi or carcinoma may be identified from tissue culture and biopsy. Moreover. They usually occur in adults and are secondary to an open wound. Bone destruction by ostemyelitis may not appear until approximately two weeks after the onset. Blood cultures are positive in up to one half of children with acute osteomyelitis. The sensitivity is 66% and specificity is 85% in one study (2) Laboratory studies : CBC may show leukocytosis. ROM and neurologic status Physical examination : If the patient has a draining sinus tract .florid reactive periostitis. Serratia marcescens and Escherichia coli are commonly isolated from chronic osteomyelitis. occurs predominantly in children and is often seeded hematogenously osteomyelitis-Subacute osteomyelitis. instability. location. If the probe contacts bone. location. deformity. Staphylococcus aureus. . History : For acute osteomyelitis .develops within one to several months osteomyelitis-Chronic osteomyelitis. -Acute osteomyelitis. aneruginosa. aneruginosa. localized bone draining pain. pathogenesis. Imaging studies : plain film radiography remain the primary investigation tool. Pseudomonas epidermidis. Additionally. ESR exceeds 70 ( sensitivity 28%).For subacute and chronic osteomyelitis . It can be classified by duration. aureus. extent and host status. erythema. the patients may have signs of systemic illness such as fever and irritability. Staphylococcus epidermidis. impaired vascularity. diagnosisperiostitis.develops after several months osteomyelitisCause : staphylococcus aureus is implicated in most cause of acute hematogenous osteomyelitis. cultures of material that was obtained by superficial swabbing of the wound and needle biopsy may inadequate and tissue for culture of aerobic and anaerobic organisms must be culture obtained during operative debridement. The 28%).
reconstructive procedures such as vascularized bone graft (18). Patients may be treated with parenteral antibiotics for 2-6 weeks depending on type of ostemyelitis and adequacy of surgical debridement. All necrotic and infected tissues are removed. midaxial incision is preferred for the phalanges and dorsal approaches for the metacarpals. After the infection is controlled and 6 weeks of antibiotics. Parenteral antibiotics may be needed for 2-6 weeks. . For severe and extensive involvement. Conservative treatment Acute hematogeneous osteomyelitis can be managed with careful evaluation of microbial etiology and 4-6 weeks course of antibiotic therapy.Treatment Treatment of osteomyelitis emphasize early diagnosis and aggressive treatment. Antibiotics should be administered for 4-6 weeks. amputation may be needed. Children with acute osteomyelitis may receive two weeks of initial parenteral antibiotic therapy before oral antibiotics(17). Surgical treatment Chronic osteomyelitis in adult is generally treated with antibiotics and surgical debridement. wrist fusion or elbow arthrodesis may be needed. For the incisions. Early antibiotic therapy produces the best results.
000/ (mm. Imaging studies : An x-ray should be obtained to identify bony destruction. 75% of total WBC count confirms the diagnosis . headache. Laboratory studies : For laboratory studies. but lower WBC count may be obtained early in the course of infection. of the fluid can be helpful. Cause : Most common organism is staphylococcus aureus History : . .Septic arthritis Definition : Septic arthritis is an infection in the joint fluid and joint tissue. Imaging with radionuclide scan destruction. and MRI are used when diagnosis is equivocal. it usually occurs as a complication of trauma or from direct spread of an adjacent infection such as felon or pyogenic flexor tenosynovitis. infection. can occur from hematogenous spreading especially in tenosynovitis. ESR and 50% C reactive protein may be useful.sup.3) or neutrophil count greater than 75% helpful. WBC count and Gram s stain useful. markedly restricted and very painful. Patients may have systemic symptoms such as fever or headache. arthrocentesis. WBC count greater than 5. Occasionally. erythema and swelling of the infected joint which held in mild flexion that maximizes the volume of the joint and minimizes the pain. painful. immunocompromised patients Physical examination : The patient usually present with pain.000/ (mm. equivocal. If joint fluid is obtained from arthrocentesis. Passive motion is pain. In the hand tissue. WBC count is elevated in fewer than 50% of patient.sup.
Treatment : Septic arthritis usually requires immediate treatment with surgical drainage. incision. irrigation. Closed continuous irrigation has been reported. reported. parenteral antibiotic and early postoperative mobilization within 24 hour The MP joint and IP joints are usually exposed through a longitudinal dorsal or dorsolateral incision. Hand therapy exercises were started during irrigation. .
HIV or neutropenia. are frequently the initiating infected bacteria. as E. syndrome. blood and tissue cultures should be under taken. be present such as Bacteroides. BUN. ESR. glucose. Physical examination : The infection spread along fascial planes under the skin. purple bullae. bacteria. The incidence is increasing in immunocompromised with diabetes. creatinine. species. alcoholism. Laboratory studies : For laboratory studies. vacular insufficiencies. CBC with differential. Klebsiella. These vesicles will fill with foul smelling pus and may begin to hemorrhage. costridial infection. neutropenia. hemorrhage. There may be bullae. :Various endotoxins released by the microbes lead to liquefactive necrosis of subcutaneous fat and fascia. general signs such as fever or severe systemic reactions. and Bacteroides species may produce gas under appropriate conditions. :As it progresses. The fatality rate may be higher if it occurs with the toxic shock countries. 20-30% cases. Clostridium. Cause : Group A hemolytic streptococci and staphylococcus aureus alone or in synegism. along with thrombosis of end arteries. rapidly spreading. Gas usually is due to infection with clostridial organisms but it does not necessarily indicate a suspected. purplish skin. inflammatory infection located in the deep fascia. IV infusions. detected. days. the infection gives way to dusky. urinalysis. syndrome. conditions. peptostreptococcus species. reactions. The majority of necrotizing fasciitis have anerobic bacteria present. History : Necrotizing fasciitis can occur after trauma. bacteria. demarcated. usually in combination with Bacteroides. IM injections . and the skin itself may not be raised or sharply demarcated. in begins with cellulitis but severe complaints of pain and then quickly spread over a course of hour to days. Other aerobic and anaerobic bacteria may synegism. aerobic gram negative bacteria. creatinine.Necrotizing fasciitis Definition : Necrotizing fasciitis is progressive. surgical procedures or around foreign bodies and it can be idiopathic also. :Anesthesia in the involved region may be detected. coli. insect bites. It is fatal in approximately 20-30% of cases. also. with secondary necrosis of the subcutaneous tissue There may be an increased incidence in African and Asian countries. organ transplants. there is sudden onset of pain and swelling. arteries. . Proteus. Typically. cancer. Imaging studies : Plain film may be use if subcutaneous gas is suspected. Psedomonas and Klebsiella.coli. taken.
anesthesia. anesthesia.Treatment 1. leading to bactericidal effect. 4. necrotic tissue and fascia. defense against infection and prevents the necrosis from spreading . extension. pain control and psychological issues 2. improved PMN function and enhanced wound healing. . Surgical debridement The surgical debridement is necessary to remove all infected. Hyperbaric oxygen therapy (HBO) HBO increases the normal oxygen saturation in the infected wounds by a thousand fold.This procedure should be performed under regional or general fascia. there are no large controlled randomized studies published to support the complete effectiveness of HBO in necrotizing fasciitis. fasciitis. 3. administered. however. It has been shown that HBO improves the tissue healing. cardiac monitoring. the fascial necrosis is typically more advanced than the appearance suggest and may spread proximally or distally that need surgical extension. Intravenous antibiotic A broad spectrum of antibiotics is administered. Supportive treatment such as fluid resuscitation. oxygen supplement.
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