Hand Infections

Hand Infections
Introduction
In the pre-antibiotic era:
65% of hand disability resulted from minor injuries that
became infected
50 - 75% of all hand deformities were the result of infection
Kanavels study of the surgical anatomy of the hand:
defined anatomical planes and channels
careful placement of incisions for optimal drainage
became the cornerstone of treatment in the pre-antibiotic
era
Penicillin changed the landscape:
severe hand infections are relatively uncommon today
incidence stable since 1940s

Hand Infections
Antibiotics
valuable adjunct in infections but used alone will
effect a cure in only a limited number of situations
early diagnosis: 24 - 48 hrs.
high dose IV therapy
elevation & splinting to rest the affected part

Beyond this time success is unlikely:

thrombosis of small vessels
swelling & pressure within closed anatomical spaces

Abx need not be continued more than 7 - 10 days

exception: osteomyelitis
can usually switch to oral route in 2 - 3 days (if
improving)

Hand Infections
Outline

Principles
High Risk Patients
Felons & Paronychia
Flexor Tenosynovitis
Deep Space Infections
Bites
IDU
Osteomyelitis
Septic Arthritis
Chronic Infections

Hand Infections
Introduction
Treatment principles
early & adequate decompression of pus to
avoid soft tissue loss
proper placement of incisions
avoids damage to adjacent structures
minimizes scar contracture

appropriate debridement of necrotic tissue

judicious splinting & early mobilization to
minimize joint stiffness
appropriate use of Abx as adjunct to prevent
dissemination of established infection

Hand Infections
Introduction
For infections requiring drainage, pre-operative
planning is required. Type & placement of
incision should:
Allow direct access to
the abscess cavity
Permit easy extension
in any direction
Follow accepted principles
of hand surgery

Hand Infections
Introduction
Principles:
carry out procedure with optimal lighting, positioning,
visualization, analgesia & tourniquet control
Do not exsanguinate part as this may cause bacterial
seeding

incisions dont cross flexion creases at > 45

avoid injury to vessels, nerves & tendons
avoid compromising the blood supply to adjacent
area
avoid leaving a sensitive scar, especially in an
important tactile area
wounds left open are packed for 48 - 72 hrs. followed
by saline soaks & exercise

Hand Infections
High Risk Patient
Up to 50% of hand infections involve:
Diabetic / Immune compromised
IDU
Bites

Higher risk for developing severe

complications:
Joint stiffness
Contracture
Amputation

- Osteomyelitis
- Necrotizing Fasciitis
- Death

Felons & Paronychia

General
Accountfor~1/3ofhandinfections

Felons
Anatomy of the fingertip
Distal phalanx is a closed sac separate from the
remainder of the digit
Closed pulp space divided into a latticework by multiple
septa
Interstices filled with eccrine glands & fat
Dorsum is rigid (bound by DP & perionychium)

An increase in pressure of this compartment can

adversely affect the blood supply to the soft
tissue & bone.

Felons
palmar closed-space infection of the distal pulp
severe pain, redness & swelling
Hx of minor penetrating trauma is usually present:
Minor cuts
Splinters
Glass slivers

most frequent causative agent: S. Aureus

untreated felons can:

extend toward the phalanx --> osteomyelitis

toward the skin --> draining sinus
obliterate vessels ---> skin slough or necrosis
supperative flexor tenosynovitis or septic arthritis of the
DIPJ

Felons
Treatment
If recognized early (mild cellulitis): soaks & Abx
Later (abscess formation): surgical drainage
Usually process has been going on > 48 hrs.

Principles:
Avoid injury to n/v structures
Utilize an incision that wont leave a disabling
scar
Do not violate flexor sheath (stay distal)
Produce adequate drainage

Felons
Treatment
Multiple incisions described:
Fishmouth
J or hockey stick

Poorchoices:
painfulscar

Through & through

unstabletip
anaesthetictip

Volar transverse
Midvolar longitudinal
Unilateral high midlateral

Risksinjurytodigital
nerve

Felons
Treatment
Palmar incisions through the center of the pulp
Avoid crossing the DIP flexion crease (contracture)
Blade should only penetrate the dermis to avoid n/v
structures and then a clamp is used to spread the
subcutaneous tissue
typically, drain over area of maximal tenderness or sinus
Disadv:: scar over tactile surface, risk injury to dig. nerve

Felons
Treatment
Unilateral longitudinal Incision
Best approach for most felons
Incise on lateral aspect of digit 5mm dorsal & distal to
the DIP flexion crease
Continue distally to a point 5mm away from the edge of
the free nail
Deepen the incision with a clamp within a plane just
volar to the palmar cortex of the DP

LocationofIncisions:
Index,middle&ring:ULNARSIDE
Thumb&small:RADIALSIDE

Paronychia
Anatomy

Paronychia
infection in and around the nail fold
Acute: any break in the seal between the nail and
nail fold may serve as a portal of entry for infection
hangnails
manicures
nail biting

usual causative agent: S. Aureus

in more advanced infections, pus may accumulate beneath
the nail plate, separating it from the underlying nail bed.
This infection involves the entire eponychium and is called an
eponychia
Pus can also spread around the nail fold resulting in a
runaround infection

Paronychia
Treatment
If recognized early (mild cellulitis): soaks & Abx
Larger infections: drainage through the nail fold
Paronychial fold & portion of adjacent eponychium:
Remove 1/4 of nail
If this doesnt allow drainage, incise fold away from
matrix

Paronychia
Treatment
Eponychia:
Elevate eponychial fold and excise prox 1/3 of nail
Lateral (paronychial) incisions may aid in separating the
nail base if not already separated

Chronic Paronychia
Slightly different disease process with an indolent course
marked by exacerbations & remissions
Etiology: proximal nail fold obstruction + fungal infection
Often seen in people whose hands are constantly in a
moist environment
Inflammation of the eponychial fold, often with
separation from the underlying nail and intermittent
drainage
usual causative agent: fungus > gram negative bacteria
Tx: eponychial marsupialization + topical antifungal
Crescent-shaped piece of skin excised proximal to nail fold
medical tx alone is largely unsuccessful

Tenosynovitis
Anatomy
Flexor sheaths are closed spaces
Extend from the mid-palmar crease
to the DIPJ
(Prox edge of A1 pulley to distal edge of A5 pulley)

Flexor sheath of small finger is

continuous proximally with the
Ulnar Bursa, while the sheath of
the thumb is continuous with the
Radial Bursa
Radial & Ulnar bursae extend
proximal to the TCL and connect
with the Parona space

(Potential space between FDP & PQ muscle)

Tenosynovitis
General
Flexor sheath infections most often as a result of
penetrating trauma
More likely at joint flexion creases
Sheaths are separated from skin by only a small amount
of subcutaneous tissue here

Also, Felons can rupture into the distal flexor

sheath
Usual causative agent: S. Aureus
most commonly affected digits:
Ring, long & index fingers

Tenosynovitis
General
Purulence within the sheath destroys the gliding
mechanism, rapidly creating adhesions that lead
to loss of function
destroys the blood supply producing tendon
necrosis

Tenosynovitis
Clinical
Kanavels 4 cardinal signs:
Tenderness over & limited to the flexor sheath
Symmetrical enlargement of the digit (fusiform)
Severe pain on passive extension of the finger (>
proximally)
Flexed posture of the involved digit

Not all four signs may be present early on

Most reliable sign: pain w. passive extension
Cellulitis of the hand may appear similar, but
swelling & tenderness is not usually isolated to a
single digit

Tenosynovitis
Treatment
Early infection < 48 hrs (& usually lacking all 4
signs) may initially be treated with IV Abx,
splinting & elevation
Failure to respond within 24 hrs. should necessitate
drainage

Established pyogenic tenosynovitis

is a surgical emergency
Requires prompt surgical drainage
Delays may result in tendon
&/or skin necrosis

Tenosynovitis
Treatment
2 basic approaches:
Open vs. Closed

Open drainage:
Decompression of the entire tendon
sheath via mid-axial & palmar incisions
Wounds are left open to drain & heal
secondarily
Rehab is prolonged; permanent finger
stiffness not infrequent
Most useful for advanced cases where
resection of necrotic tendon is required

Tenosynovitis
Treatment
Closed tendon-sheath irrigation:
2 incisions made
Proximal palm: open the sheath proximal to the A1 pulley
Distal mid-axial: open sheath distal to the A4 pulley
Long irrigation catheter (16 - 18g) is placed in the proximal
sheath with a drain left in the distal incision
Incisions are then closed, and sheath is irrigated for 48 - 72
hrs.
May use NS or Abx solution (continuous drip or q2h flush)
Addition of marcaine alleviates pain of irrigation
Modification involves multiple transverse incisions of
cruciate pulleys with insertion of silastic drains

Tenosynovitis
Treatment
These incisions:
ensure adequate drainage
heal quickly
Do not interfere with rehab

After removal of catheter and

drains begin gentle passive &
active ROM

Chronic Tenosynovitis
Unusual cases may be seen which present differently
than acute pyogenic infections:
Chronic swelling of the flexor sheath
No disabling pain or loss of function

These are chronic infections most frequently caused by

mycobacteria
usually the result of a puncture wound in an aquatic
environment
M. Kansasii or M. Marinarum

Dx: AFB stains & culture of synovium

Tx: tenosynovectomy + antituberculous drugs (6 - 24
mo)

Deep Space Infections

4 deep spaces clinically significant in hand
infections:

Subfascial palmar space

Dorsal subaponeurotic space
Thenar space
Midpalmar space

Deep Space Infections

Subfascial Palmar Space Infections
subfascial palmar space communicates with the
dorsal subcutaneous space via web spaces between
the digits
usually spread dorsally (collar button abscess)
Double abscess: +/- palmar & dorsal abscesses connected
through hole in fascia
Palmar spread is limited by the relationship of fascia to skin

Causes:
Fissure in the skin between the fingers
Distal palmar callus (MC head)
Extension from subcutaneous infection in proximal finger

Severe distal palmar swelling with an abducted finger

Puss-filled web spaces

Subfascial Palmar Space Infections

Treatment
2 important points:
Do not incise web space transversely
Be alert for the double abscess configuration

Drainage is via a palmar approach with division of

the palmar fascia to expose both the volar &
dorsal compartments

Deep Space Infections

Dorsal Subaponeurotic Space
Infections

DSS is beneath the extensor tendons on the

dorsum of the hand
Often the result of penetrating trauma
IDUs
neglected human bites

Dorsal swelling, erythema & tenderness + history

make the diagnosis
Drain via linear incisions over the 2nd & 4th MCs
while preserving soft tissue coverage over the
tendons
occasionally direct incision over a pointing abscess is
necessary
Risks exposure (desiccation) of extensor tendons

Deep Space Infections

Thenar Space Infections
Thenar space follows the direction of Adductor
Pollicis:
Dorsal: AP muscle
Volar: index flexor &
1st lumbrical
Radial: insertion of AP
(proximal phalanx of the thumb)
Ulnar: oblique septum from
skin to the 3rd MC

Thenar Space Infections

Clinical
Causes:
penetrating injury
thumb or index subcutaneous abscess
thumb or index flexor tenosynovitis
extension from radial bursa or
midpalmar space
marked swelling of the thenar
eminence & 1st web space
thumb forced into abduction
severe pain with extention or opposition
infection tracks dorsally via 1st web space,
over the AP & 1st dorsal interosseous muscles.

Thenar Space Infections

Treatment
Drain via volar or dorsal incisions
in the 1st web space or both:
Identify neurovascular structures
unroof the adductor fascia to open
the abscess cavity
irrigate & debride
catheter in volar incision & close;
penrose in dorsal incision & close
compressive dressing & plaster splint

Deep Space Infections

Midpalmar Space Infections
Boundaries:
Dorsal: intrinsic muscles
Volar: flexor tendons
Radial: oblique septum from
the skin to the 3rd MC
Ulnar: hypothenar muscles
Distal: vertical septa of palmar fascia
Prox: fascial layer at distal carpal tunnel

Deep Space Infections

Midpalmar Space Infections
Clinical:
usually due to direct penetrating trauma, rupture of
tenosynovitis
loss of palmar concavity, dorsal swelling, tenderness
volarly

Midpalmar Space Infections

Treatment
Drain via wide palmar incisions
with +/- resection of palmar fascia
to ensure drainage of abscess cavity.
or may place irrigation catheter &
drain and close primarily.

Bursal Infections
Usually due to spread of flexor tenosynovitis from
thumb or small finger
Radial bursa:
Proximal extension of
tendon sheath of FPL
extends through the carpal
tunnel into the distal forearm

Ulnar bursa:
Proximal extension of tendon
sheath of FDP of small finger

Bursal Infections
Treatment
Closed irrigation using 2 incisions, a catheter & a
drain as previously outlined.

Human Bites
Often undertreated & misdiagnosed leading to
significant morbidity
The most serious form of human bite infection is
the clenched fist injury:

Any laceration over the head of a

metacarpal is a human bite injury
until proven otherwise

Human Bites
The wound that results from a punch to the mouth
may appear insignificant and treatment may not be
sought for days.
It often results in immediate inoculation of the
subcutaneous tissue, the subtendinous space and
the MCP joint with saliva
Human saliva may contain over 10 8 microorganisms per ml.
Over 42 species of bacteria identified
Thus: Polymicrobial infection is the rule

Common organisms:
S. Aureus, Strep sp.,
Eikenella: gram neg facultative anaerobe in ~ 30% (incr.
severity)

Human Bites
Delay in onset of treatment is directly proportional
to poor outcomes:
In general, human bites treated within 24 hrs. rarely have
serious complications

in E.D.:
Debride, irrigate, pack open
Abx to cover gram +s & eikenella (Pen & Ceph)
+/- admission to follow response

To O.R.:
Established joint space penetration, & more severe
infections

Animal Bites
Dog more common than cat (5%)
Cat bites are particularly virulent & can result in deep
puncture wounds that are hard to clean

More than half involve kids

Basic principles of debridement & irrigation apply
Deep puncture wounds are left open & may require
extension
Established infections are debrided & packed open
Superficial lacerations may be loosely closed after irrigation

Common organisms:
S. Aureus, Strep viridans, Pasturella (#1 in cats), anaerobes

Abx: ampicillin (Clavulin on outpatient basis)

Injection Drug Use

Common sites of infection:

Dorsum of hand
Radiodorsal area of the wrist
Palmar aspect of the forearm
Dorsum of the fingers at the PIPJ

Clinical spectrum:

Cellulitis
Subcutaneous abscess
Flexor tenosynovitis
Septic joints
Osteomyelitis
Necrotizing fasciitis

Injection Drug Use

Source of infection from a variety of sources
Skin
Saliva
Bowel

Tx:

Admission
elevation of limb
broad spectrum IV Abx
analgesia (may need support from APS or CDRT)
+/- debridement & irrigation
Medicine consult

Hand Infections
Osteomyelitis
Almost always the result of adjacent spread
wound infection
joint infection
tenosynovial infection

Also, direct penetration

(hematogenous spread is rare)
most commonly S. Aureus
Bone necrosis: hallmark
microorganisms reside in dead bone

If caught early, before extensive bone necrosis

occurs, it may be cured with Abx alone.

Osteomyelitis
Diagnosis
Xrays:
Early radiographs may be normal
It takes at least 10 days for matrix
to mineralize & areas of increased
density to be detected.
Lytic lesions; sclerosis (1 month)

Bone Scan:
Can pick up osteomyelitis early, but less specific

Prompt surgical exploration is the most reliable

way to establish the diagnosis

Osteomyelitis
Treatment
Approach depends on location of involved bone:
Phalanx: mid-axial incision
Metacarpals: dorsal approach

all infected bone must be removed

Soft bone may be curetted
may need to use drill holes to remove a small window of
cortical bone for decompression of the infection

routine post-Op care or may also use constant

irrigation methods (1 wk)
severe, extensive involvement of a digit may be
best treated by amputation
Will prevent stiffness & major disability of the uninfected
parts

Hand Infections
Septic Arthritis
usually the result of penetrating trauma:
bite or tooth wound

also, spread from soft tissue or bony infection

joint is swollen, warm & tender
pain with axial loading
passive motion is restricted & painful

Xrays:
thinning of joint (cartilagenous loss)
resorption of subchondral bone
osteomyelitis (late)

aspiration of joint for C & S

Septic Arthritis
Treatment
Drainage is imperative as soon as the diagnosis is
made
Destruction of the articular cartilage by lysozymal
activity

approach is through a longitudinal dorsolateral

incision over the affected joint
access to the joint is via an incision dorsal to the
cord portion of the collateral ligament
joint is irrigated & debrided
packed open for 48 - 72 hrs. (or closed over irrigation)
packing removed and gentle ROM begun
wound granulates closed

Hand Infections
Chronic Infections
Atypical mycobacterium infections:
penetrating wound often in a marine environment
prolonged, relatively non-painful swelling of finger, palm or
wrist
Tuberculous & atypical mycobacteria have a predilection for
synovial tissue of joints & tendon sheaths
Tenosynovium is thick, infected & hypertrophic. It surrounds
the tendons & erodes the pulleys.
Dx: culture synovial biopsy
Noncaseating granulomas & AFB

Tx: thorough joint synovectomy

For ++ joint damage: rest the joint until the infection is cured
before undertaking reconstruction
For tenosynovium: complete synovectomy sparing the pulleys
Start anti-TB meds empirically (around time of synovectomy)

Hand Infections
Chronic Infections
Tuberculous Infections:
less common now than several decades ago
Presents in a similar manner as atypical
mycobacterial infections
Tx: as above, synovectomy + anti-TB drugs
In addition, can produce a dactylitis
Enlarged fingers
Proliferation of subperiosteal reaction on Xray

Tx: surgical excision & curettage of the

involved areas

Hand Infections
Chronic Infections
Leprosy:
M. lepraemurium
Predilection for cooler areas of the body including the
hands
Most frequently produces a neuropathy involving the
ulnar nerve:
intrinsic atrophy
clawing
weakness in pinch

Tx: surgical procedures limited to reconstruction for the

neurological deficits

Hand Infections
Chronic Infections
Fungal Infections:
except for biopsy for diagnostic purposes, surgical
treatment is rarely necessary
best treated with systemic &/or local anti-fungal agents
occasionally a tenosynovitis, septic arthritis or
osteomyelitis is seen:
Appropriate debridement required as above
Mainstay is still anti-fungal agent

Post Op Care
Wound care & early initiation of therapy are key
in achieving good functional results in treating
hand infections
In general:

wounds are debrided, irrigated & packed open

packing usually removed 24 - 48 hrs. post-op
initiation of regular wound cleansing
gentle active ROM
splints may be helpful in enhancing joint motions
early involvement of a hand therapist is important in
achieving a good functional result.