Management of acute infections of the hand by Dr Vivek Singh AIIMS R

1. Hand infections
Dr Vivek Singh
23/4/2017

2. Nail Anatomy

3. Paronychia
 Infection of the lateral nail fold
 Most common
 Eponychia
 Run-around infection

4. Paronychia
 Staph aureus most common although most are mixed
 Violation of the seal between nail plate and nail fold
 Risk Factors
 Hangnails,
 Manicures,
 Penetrating trauma,
 Constant exposure to a wet environment,
 Nail biting or sucking

5. Swelling,
erythema &
tenderness
with
progressio
n to
abscess
formation.
Spontaneous
decompression
can occur,
(subungual
abscess).
Deeper
infections
can involve
the nailbed,
pulp space,
and bone
Paronychia-Clinical presentation

6. Paronychia
 Laboratory evaluation if not responding to
initial treatment
 Radiographs if long-standing infection, foreign
body or osteomyelitis

7. Paronychia-Treatment
 Early stage
Oral antibiotics,
Warm soaks in Povidone-iodine
Rest and observation
 Surgical decompression
 Keep blade away from nail bed
 A small wick is placed for 24 to 48 hours

8. Paronychia-Treatment
 Infection that travels below the nail plate -
remove a portion of the nail.
 If the entire nail matrix is involved,then the
entire nail is removed.

9. Chronic Paronychia
 Indurated, painful eponychium
 Frequent water immersion-predisposing
 Intermittent acute infections
 Diabetes and psoriasis predisposing
 Gram-positive,negative, Candida,mycobacterial

10. Chronic Paronychia
 Marsupialization
 Nail removal if deformed
 Protect the germinal matrix
 Oral antibiotics for 2 weeks
 Change if Mycobacterial
 Early finger ROM

11. Felon
◦ Deep space infection of the distal pulp
◦ Differs from apical infections
◦ Multiple septal compartments
◦ Most frequent S. Aureus
◦ 15% to 20% of all hand infections.

12. Felon
 Penetrating trauma
 Hematogenous spread
 Finger stick felon
 Most common in thumb & index finger.
 Throbbing pain
 Tense swelling localized to the pulp

13. Felon
 Extend toward the phalanx --> osteomyelitis
 Toward the skin --> draining sinus
 Obliterate vessels ---> skin slough or necrosis
 Suppurative flexor tenosynovitis
 Septic arthritis of the DIPJ

14. Felon-Treatment
 Aim-Preserving the function of distal phalanx.
 Don’t wait for fluctuation if tension is severe
 If recognized early (mild cellulitis): soaks & antibiotics
 Abscess(48 hrs): surgical drainage

15. Felon-Treatment Principles
 Avoid injury to nerve and vessels
 Don’t leave a disabling scar
 Do not violate flexor sheath
 Produce adequate drainage
 Keep wound open

16. Pyogenic Flexor Tenosynovitis
 Synovial sheath
 Extend from the mid-palmar
crease to the DIPJ (A1 to A5)
 Small finger-Ulnar bursa
 Thumb sheath-Radial Bursa
 Parona space

17. Pyogenic Flexor Tenosynovitis
 Penetrating trauma
 Felons can rupture
 Purulence destroys the gliding mechanism
 Tendon necrosis possible
 Usual causative agent: Staph. Aureus
 Pasteurella multocida -animal bites.
 Immunocompromised -Mixed gram –and+

18. Kanavel’s 4 cardinal signs
Severe pain on passive
extension of the finger
(most reliable)
Kanavel A: Infections of the Hand. 7th ed. Philadelphia, Lea &
Febiger, 1939.

19. Pyogenic Flexor Tenosynovitis-Treatment
 Early infection < 48 hrs- IV Abx,
splinting & elevation
 Failure to respond within 24 hr -
drainage
 Established pyogenic tenosynovitis
is a surgical emergency

20. Treatment
 2 basic approaches:
 Open vs. Closed

21. Closed tendon sheath irrigation

22. Deep Space Infections
 Hand-three potential palmar spaces.
 Forearm has one potential space.
 Hand-three superficial spaces

23. Deep Space Infections
 Swelling particularly on the dorsal side.
 Distinguish from local dorsal abscess
 X-Ray for retained foreign body, OM, or fracture.
 Aspiration, ultrasound, or MRI may be useful .

24. Thenar Space Infections

25. Thenar Space Infections
• Most common of deep space infection
• Cause-Penetrating injury
• Thumb or index subcutaneous abscess
• Thumb or index flexor tenosynovitis
• Extension from radial bursa or midpalmar space

26. Thenar Space Infections
• Marked swelling
• Thumb forced into abduction
• Severe pain with extension or opposition
• Infection tracks dorsally -Dumbbell or Pantaloon
abscess

27. Thenar Space Infections-Treatment
 Treat as a surgical emergency
 Drain via volar or dorsal incisions or both
 Identify neurovascular structures
 Irrigate & debride
 Close over drain
 Compressive dressing & plaster splint

28. Midpalmar Space Infections

29. Midpalmar Space Infections
Direct penetrating trauma,
Rupture of septic tenosynovitis
Loss of palmar concavity,
Dorsal swelling,
Pain on passive extension

30. Midpalmar Space Infections-Treatment

31. Deep Subfascial Space Infections
1. Dorsal subcutaneous space
2. Dorsal subaponeurotic space
3. Interdigital web space-collar-button abscess

32. Deep Subfascial Space Infections
 Dorsal Subcutaneous and Dorsal Subaponeurotic Space Abscess
 Penetrating injuries
 Dorsal aspect of the hand swollen,warm and tender.
 Finger extension difficult and painful.
 Differentiating from cellulitis or other hand infections difficult

33. Deep Subfascial Space Infections
 Web Space Abscess (Collar-Button Abscess)
 Hourglass shape
 Cause-fissure in the skin between the fingers
 Pain and swelling localized to the web space
 Swelling either palmar or dorsal aspect
 Finger abduction

34. Deep Subfascial Space Infections-
Treatment
 Dorsal Subcutaneous and Subaponeurotic Space Abscess
 One or two dorsal longitudinal incisions
 Determine whether infection is superficial or deep
 Subaponeurotic space opened by incising along margin of the
extensor tendon

35. Deep Subfascial Space Infections
 Collar-Button Abscess
 Most important aspect-Treat both dorsal and volar components
 Both dorsal and volar incisions

36. Deep space infections-Aftertreatment
 Keep wounds open
 Gauze wick for 48-72 hrs
 After 72 hrs soaks in Povidone-iodine
 IV Antibiotics 10 days
 Oral antibiotics 4 weeks
 Early active motion

37. Summary
 Careful history & examination
 Anatomical area involved
 Extent of spread
 Empiric antibiotics till culture report
 Prompt and adequate surgical treatment
 Immobilization in position of function
 Rehabilitation

38. Thank you