Infection of the Hand

Alyaa FarhanSyahida 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

InfectionAcute

inflammatory reaction

Causing oedema, suppuration and increased tissue

tension

In closed compartment, high pressure may

threaten blood supply tissue necrosis

Neglected case infection may spread from 1 compartment

to another

There is also a danger of lymphatic and haematogenous

spread

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 InfectionsParonychia

FelonSuppurative Tenosynovitis

Deep Fascial Space InfectionSeptic Arthritis

BitesMycobacterial Infections

Fungal infections

Paronychia (Nail Fold Infection)

• Commonest

• Seen most in children or in older people after rough nail-trimming

• 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 patient’s

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 – Can’t be moved

Flexed posture of digit

Tenderness along the course

of the tendon

Pain on passive finger

extension

Pain on active flexion

Kanavel’s signs of flexor sheath infection

• 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 Parona’s 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 BitesHuman 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

• Fishmonger’s 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