Discuss the Management of

Severe Hand Infections in a

young farmer
By Dr Lawson B
Dept of Surgery

Outline
I.

II.

Introduction
-historical background
-surgical anatomy
-definition/ classification
-aetiopathophysiology
Management
-presentation
-history

Outline

III.

-examination
-investigations
-principles of treatment
-treatment
-complications
-outcome and prognosis
-prevention
Conclusion

Introduction

Surgery derived from chirurgerie meaning hand work;

underlying the importance of the hand to our discipline as well
as the rest of mankind.
Farming exposes the farmer to penetrating trauma and bites
from his animals with a wide range of organisms.
Hand infections can range from simple routine conditions to
devastatingly debilitating surgical emergencies that result in
significant compromise of hand infection.
Hence the surgeons mastery of hand infections and their
management may determine the future of his patients.

Historical background

Kanavel 1939

Surgical anatomy

The location and spread

of hand infections is
dictated by fascial
planes.
These are divided into
superficial and deep
spaces.

Surgical anatomy

Definition and Classifications

a)

b)

c)

Hand infections are

classed thus
Superficial e.g.
paronychia, felon
Deep e.g. flexor
tenosynovitis, septic
arthritis, osteomyelitis
Unclassified

Deep hand infection are

also considered severe
hand infections

Aetiopathophysiology
Aetiology
Penetrating trauma
Animal bites
Agents
commonly bacterial
S.aureus commonest
streptococci, clostridium, anaerobes
Mycobacterium species in our environment
mixed organisms in diabetics and other
immunocompromised conditions

Aetiopathophysiology

Pathology
infection inflammation oedema

Management

Early, accurate, careful, gentle, painstaking assessment.

This is a surgical emergency!
History
-hand pain, swelling, loss of function, drainage
-penetrating trauma, animal bites
-onset, duration
-constitutional symptoms
-hand dominance
-premorbid - Diabetes

Management (contd.)

Examination
1. General - ill looking, painful distress, febrile
2.Specific
-Look
*skin- point of trauma, bruises, bite point, pointing
of the abscess
*soft tissues- edema
*bones deformity ( in osteomyelitis)
*joint swelling (in septic arthritis)

Management (contd.)
Examination
2. Specific
-Feel
*skin- sensation
*soft tissues- tender fluctuant swelling,
generalized tenderness of the hand.
*bone and joints- deformity ( osteomyelitis), jt
swelling, tenderness( septic arthritis)

-Move

Management (contd.)
Active- limitation of ROM of hand
PassiveKanavels signs- 1. flexed position of the digit
2.fusiform swelling of the digit
3.pain with passive extension
4.tenderness along course of flexor
tendons
All can be seen in flexor tenosynovitis but the last is
diagnostic though all can be absent

Management (contd.)

a)
b)
c)
d)
e)
f)
g)

Differentials
Herpetic whitlow
Fracture of the digits
Trigger finger
Inflammatory tenosynovitis
Gout
Arthritis
Dactylitis

Management (contd.)
Investigations
# aspirate/ pus for m/c/s
#FBC, ESR- wbc with neutrophilia, ESR
#RBS- diabetes
#X-rays- hand (3 views), sequestrum, involucrum
seen in Osteomyelitis; widening of joint space in SA
-Septic arthritis
#Joint aspirate for macroscopy, m/c/s, biochemistry

Management

1.

Treatment
Appropriate antibiotic coverage- Initially
oral/ parenteral empirical penicillinase
resistant antibiotics or 1st gen cephalosporin
AFTER SAMPLES ARE OBTAINED e.g.
Sulbactam, combined with metronidazole.
Then culture sensitive antibiotics.
Adequate analgesia e.g.opiods/ NSAIDS,
antitetanus prophylaxis.

Management

2.

Treatment
Surgical drainage of pus
Surgical Principles
Adequate anaesthesia (G.A / Biers block)
Tourniquet to ensure bloodless field. Do not
exsanguinate with bandaging. Should be well
padded. Tourniquet time is 1.5-2hrs.
Appropriate positioning of hand and sitting of
surgeons
Incisions

Management (Incisions)

Management

Flexor tenosynovitis incision, drainage and

continuous irrigation via a catheter

Deep palmar infections- incision over the most

fluctuant points on dorsal and palmar surfaces

Septic arthritis Arthrotomy, Irrigation with(out)

debridement

Osteomyelitis- sequestrectomy with(out)

debridement, ant

Management

Post operatively
Elevation on pillow
Correct splinting
Aggressive and early rehabilitation once
infection is controlled to prevent stiffness.

Splinting

Splint in the position of function (Edinburgh

position) - wrist extension of 15-30, MCP
flexion of 70-90, and IP extension

Complications

a)
b)
c)
d)

e)
f)

Hand infections
Tendon destruction
Sepsis
Functional disability
Extension into the
forearm
Sepsis
Compartment
syndrome

a.

b.

Surgical intervention
injury to hand
structures

Management

Outcome and Prognosis

Rapid precise diagnosis, quick surgical intervention
and informed follow-up make a significant
contribution to restoration of hand function.
Prevention
1- Use of heavy duty hand gloves, immunization of
farm animals
2 -Early presentation and cooperation with
physiotherapy.

Conclusion

The hand is significant to livelihood,

appropriate understanding of hand infections
and their diagnosis could be the difference
between a surgeon remaining in practice and
losing his job.