Infection of the Hand

Alyaa Farhan Syahida Hanim

Outline
Pathology Clinical features Principle of treatment Diseases :
(i) Paronychia (ii) Felon (iii) Suppurative tenosynovitis (iv) Deep fascial space infection (v) Septic Arthritis (vi) Bites (vii) Mycobacterial infection (viii) Fungal infection

Pathology
Causing oedema, suppuration and increased tissue tension

Infection

Acute inflammatory reaction

There is also a danger of lymphatic and haematogenous spread

Neglected case infection may spread from 1 compartment to another

In closed compartment, high pressure may threaten blood supply tissue necrosis

Clinical Features
Usually there is history of trauma (superficial abrasion, laceration or penetrating wound) Few hours or days later, fingers / hands become painful (throbbing) Ill and feverish Predisposing conditions (DM, IVDU and immunosuppression)

Local Examination
Redness of the skin Swelling Local tenderness Superficial infection able to flex infected finger Deep infection unable to flex the infected finger Lymph node (Swollen, Lymphagitis) General examination look for sign of septicemia

Investigation
X Ray - Unhelpful in early stages of infection
- Few weeks later (may show features of osteomyelitis, septic arthritis or bone necrosis)

Bacteriological examination (pus)

Septic Arthritis

Osteomyelitis

Principles of Treatment
4 principles : Antibiotics
Rest, Splintage and elevation Drainage Rehabilitation

Antibiotics
Starts immediately after the clinical diagnosis is made Flucloxacillin or cephalosporin If suspect bone infection add fucidic acid For bites give broad spectrum penicillin Change antibiotic when bacterial sensitivity is known

Rest, splintage and elevation

Analgesic is given Hand must be splinted in the position of safe immobilization
(wrist slightly extended, MCP joints in full flexion, IP joints extended and thumb in abduction)

Arm is held elevated

Drainage
Signs of abscess drainage culture End of operation hand is splinted in the position of safe immobilization A sling is used to keep the arm elevated

Post operative rehabilitation

Signs of acute inflammation resolved starts movement (under guidance of hand therapist)

Hand Infections
Paronychia Felon Suppurative Tenosynovitis Deep Fascial Space Infection Septic Arthritis Bites Mycobacterial Infections Fungal infections

Paronychia (Nail Fold Infection)

 Commonest Seen most in children or in older people after rough nailtrimming Clinical features:
Edge of nail fold red, swollen and tender Abscess may form in the nail fold If left untreated, pus can spread under the nail

 Treatment:
At first sign of infection, antibiotics may be effective. If pus present, it must be released by an incision.

If pus has spread under the nail, part or all of the nail may need to be removed.

 Chronic paronychia
May be due to:
Inadequate drainage of an acute infection A fungal infection which require specific treatment

Topical or oral antifungal used to eradicate infection If fail with antifungal, nail bed may have to be laid open - marsupialized

Felon (Pulp Infection)

 Usually caused by a prick injury.

Most common organism Staphlycoccus aureus Clinical features:

Throbbing pain in the fingertip Red, swollen and acutely tender

 Treatment:
If recognized early, antibiotic and elevation of hand is sufficient. If abscess formed, pus is released by small incision over the site of maximum tenderness. If treatment delayed, infection may spread to bone, joint or flexor tendon sheath. Post-operatively, finger is dressed and antibiotic is modified and continued.

Herpetic Whitlow

Organism herpes simplex virus. Route:

Auto-inoculation from the patients own mouth or genitalia. Cross infection during dental surgery.

Clinical features:
Small vesicles Coalesce and ulcerate.

Subsides after 10 days and may recur. Treatment aciclovir at early stage.

Suppurative Tenosynovitis (Tendon Sheath Infection)

Tendon sheath is a closed compartment extending from the distal palmar crease to the DIP joint.

 Uncommon but dangerous.

Usually follows a penetrating injury. Organism Staphylococcus aureus, streptococcus and Gram-negative organisms. Clinical features:
Painful and swollen Held in slight flexion Cant be moved

Kanavels signs of flexor sheath infection

Flexed posture of digit

Tenderness along the course of the tendon

Pain on passive finger extension

Pain on active flexion

 Consequences:
Delayed diagnosis vascular occlusion and tendon necrosis Neglected infection, may spread proximally to:
ulnar and radial bursa horse shoe abscess Flexor compartment at wrist and Paronas space in forearm median nerve compression

 Treatment:
Hand is elevated, splinted and antibiotics are administered IV. No improvement after 24 hours, surgical drainage is essential. Post-operatively, hand is swathed in absorbent dressing and splinted in the position of safe immobilization. Hand therapy if there is stiffness.

Deep Fascial Space Infection

 4 potential spaces
Thenar space Midpalmar space Dorsal subaponeurotic space Subfacial web space

 Infection from
Direct penetrating trauma Contiguous spread Hematogenous spread

S. aureus, strep, occ. coliforms and anaerobes

 Thenar space infection

Pain and swelling of thenar eminence and first web space Can be from tenosynovitis of 2nd digit with rupture proximally Thumb is held abducted and flexed

Midpalmar infection
Loss of normal hand concavity Tenderness of central palm Pain with movement of 3rd and 4th digits Can be from tenosynovitis of digits 3,4,5

 Treatment for all

IV antibiotics Amp/Sulb Hand consult for open exploration and drainage

Septic Arthritis

 Affecting any of the MCP or fingers joint. Route:

Direct by penetrating injury or intra-articular injection Indirect from adjacent structures occasionally through hematogenous spread.

Organism Staphylococcus aureus, Streptococcus, Haemophilus influenza. Common cause of MCP infection is fight-bite.

 Clinical features:
Pain, swelling and redness of single joint Restricted movement

Indistinguishable from acute gout

Presence of lymphangitis/systemic features may help In their absence, joint aspiration may help.

 Treatment:
IV antibiotics are administered and hand is splinted. Inflammation persist after 24 hours or there is sign of pus, open drainage is needed.

Post-operatively, copious dressing is applied and hand is splinted in the position of safety for 48 hours then movement is encouraged. IV antibiotics are continued until all signs of sepsis have disappeared.

BITES
Animal Bites Human Bites

 Animal bites:
Usually inflicted by cats, dogs, farm animals and rodents. May become infected. Organisms staphylococcus, streptococci, Pasteurella multocida.

 Human bites:
More prone to infection.

Organisms Staphylococcus aureus, Streptococcus Group A and Eikenella corrodens.

Involve any part of the hand, fingers. The tell-tale signs of human bite lacerations on both volar and dorsal surfaces of the finger.

Fist fight consist only the dorsal wound over the one of MCP knuckles.

 Investigation:
Xray Swab for c+s

Treatment:
Fresh wounds
Debridement. Hand is splinted and elevated. Antibiotics given as a prophylaxis.

Infected wounds
Debridement and wash-outs. IV antibiotics broad spectrum penicillins.

Post-operatively
Copious wound dressings. Splintage in safe position. Encourage movement once infection resolved

Mycobacterial Infections

 Fishmongers infection
Chronic infection caused by Mycobacterium marinum.
Organism is introduced by prick injuries from fish spines or hard fins. May appear as a superficial granuloma. Deep infection can give rise to an intractable synovitis of tendon or joint. Diagnosis require biopsy. Treatment:
Superficial lesions heal on their own or otherwise need to be excised. Deep lesions require surgical synovectomy. Prolonged antibiotic to prevent recurrence. Reommended broad spectrum tetracycline. Or else chemotherapy with ethambutol and rifampicin.

 Tuberculous tenosynovitis
Uncommon. Diagnosis should be considered in patients with chronic synovitis once has excluded rheumatoid diseases. Confirmed by synovial biopsy. Treatment: synovectomy and prolonged chemotherapy

Fungal infections

 Superficial tinea infection

Common Palm and interdigital clefts Controlled by topical preparations

Tinea of nail
Difficult to eradicate Require oral antifungal and complete removal of nail

Opportunistic fungal infection

Occur in debilitated and immunocompromised patients

 Subcutaneous infection
Usually caused by thorn prick Chronic ulceration at the prick site Unresponsive to antibiotic Confirmed by microbacterial culture Treatment: oral potassium iodide

Deep mycotic infection

May involve tendons or joints Confirmed by microscopy and microbiological culture Treatment: local excision and IV antifungal Resistant case require limited amputation

Thank You