26I MODERN TRENDS IN THE TREATMENT OF INFECTIONS OF THE HAND By R. P. JEPSON, F.R.C.S., and H. BOLTON, F.R.C.S. From the Surgical Professorial Unit, The Royal Infirmary, Manchester The methods of treatment advocated in this paper are based on the personal experiences of the authors over the past three years. Some indica- tion as to the frequency of hand infections at a general hospital and the material studied will be evident from the following statistics. Only the more common and important septic lesions are included. New Patients Attending the Septic Hand Clinic I946 .. .. .. .. .. I,68o 1947 . .. .. .. .. 2,076 I948 .. .. .. .. .. 1,8o6 Analysis of Cases for 1948 Pulp space infections .. .. .. 24 per cent. Paronychia (acute and chronic) .... 25 ,, Phalangeal infections .. ... I ,, Web space infections .. .. .. 5 ,, Boils and carbuncles .. .. 6 Miscellaneous (including subcuticular in- fections, septic lacerations, bums, abrasions) -. .. .. .. 28 ,, Tendon sheath infections .. .. 4 cases Palmar space infections .. .... 2 ,, Erysipeloid of Rosenbach .. .. 2 ,, Average number of attendances per patient ..... .. .. . 7 Average number of patients attending each day .. .. .. .. .. 44 Average duration of treatment .. .. I6 days It is important to realize that most hand in- fections can be avoided, aborted or brought under early control if adequate working precautions and early first-aid facilities are available. In this paper we shall deal, however, not with the prophylaxis but with the treatment of established hand infections. Pulp Space Infections (Felons) The frequency of these lesions and their com- mon association with massive soft tissue necrosis and osteitis make them the most important group attending the infected hand clinic. If treatment is delayed or inadequate, a poor tactile pad and a stiff finger follow. A lateral transpulp incision is complicated in 2 per cent. of patients by a persistent painful state, The latter will be described in more detail later. Approximately 24-5 per cent. of the total workmen's compensation claims are for septic hand lesions, and a considerable percentage of these follow pulp space infections. Before adequate therapy can be administered the natural history of these lesions must be understood. The organism causing the primary infection is almost always a staphylococcus aureus, coagulase positive (Bolton, Catchpole and Jepson, I947). It is introduced into the pulp pad by a prick or cut in about half the cases and in those who can remember no local injury it is assumed to enter by way of a sweat gland. The bacteria may be transient or resident on the hand skin and a recent investigation (Moss, et al., 1948) suggests that a common source of the organism is the nasal vestibule, the contamination being by direct hand to nose contact. Once the organism is established in the fibro- fatty pulp space of the finger, a cellulitis arises during which stage the patient complains of a 'pricking' or 'tight' pain. This early in- flammatory reaction is situated between the stout fibrous septa running from skin to periosteum; it may resolve spontaneously or with the aid of chemotherapy. Should resolution not occur, pus is formed. The resulting abscess is limited by the fibrous trabeculae to one or more of the fibro-fatty com- partments and involves only a portion of the pulp space. As the abscess grows it spreads in one or more of three directions :--(a) through the periosteum to involve the terminal phalanx (or occasionally round the side of the bone to present as a' paronychia'); (b) through the skin in front forming at first a collar-stud abscess under the horny layer; (c) through the containing fibrous walls at its sides to the rest of the pulp space (Fig. I). Usually the skin and periosteum give way first, so that a skin sinus or an osteitis arises before the whole of the pulp space is involved. If left untreated the outcome of a pulp space abscess depends therefore on its site. If superficial, a skin sinus develops and by discharging the pus and slough, may lead to a spontaneous cure. The deeper abscesses and especially the more distal copyright. on March 28, 2021 by guest. Protected by http://pmj.bmj.com/ Postgrad Med J: first published as 10.1136/pgmj.25.284.261 on 1 June 1949. Downloaded from
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26I
MODERN TRENDS INTHE TREATMENT OF INFECTIONS OF THE HAND
By R. P. JEPSON, F.R.C.S., and H. BOLTON, F.R.C.S.From the Surgical Professorial Unit, The Royal Infirmary, Manchester
The methods of treatment advocated in thispaper are based on the personal experiences of theauthors over the past three years. Some indica-tion as to the frequency of hand infections at ageneral hospital and the material studied will beevident from the following statistics. Only themore common and important septic lesions areincluded.
Analysis of Cases for 1948Pulp space infections .. .. .. 24 per cent.Paronychia (acute and chronic) .... 25 ,,Phalangeal infections .. ... I ,,Web space infections .. .. .. 5 ,,Boils and carbuncles .. .. 6Miscellaneous (including subcuticular in-
Tendon sheath infections .. .. 4 casesPalmar space infections .. .... 2 ,,Erysipeloid of Rosenbach .. .. 2 ,,Average number of attendances per
patient ..... .. .. . 7Average number of patients attending
each day .. .. .. .. .. 44Average duration of treatment .. .. I6 days
It is important to realize that most hand in-fections can be avoided, aborted or brought underearly control if adequate working precautions andearly first-aid facilities are available. In this paperwe shall deal, however, not with the prophylaxisbut with the treatment of established handinfections.
Pulp Space Infections (Felons)The frequency of these lesions and their com-
mon association with massive soft tissue necrosisand osteitis make them the most important groupattending the infected hand clinic. If treatment isdelayed or inadequate, a poor tactile pad and astiff finger follow. A lateral transpulp incision iscomplicated in 2 per cent. of patients by a persistentpainful state, The latter will be described in more
detail later. Approximately 24-5 per cent. of thetotal workmen's compensation claims are for septichand lesions, and a considerable percentage ofthese follow pulp space infections. Before adequatetherapy can be administered the natural history ofthese lesions must be understood. The organismcausing the primary infection is almost always astaphylococcus aureus, coagulase positive (Bolton,Catchpole and Jepson, I947). It is introduced intothe pulp pad by a prick or cut in about half thecases and in those who can remember no localinjury it is assumed to enter by way of a sweatgland. The bacteria may be transient or residenton the hand skin and a recent investigation(Moss, et al., 1948) suggests that a commonsource of the organism is the nasal vestibule, thecontamination being by direct hand to nosecontact.Once the organism is established in the fibro-
fatty pulp space of the finger, a cellulitis arisesduring which stage the patient complains of a'pricking' or 'tight' pain. This early in-flammatory reaction is situated between the stoutfibrous septa running from skin to periosteum;it may resolve spontaneously or with the aid ofchemotherapy. Should resolution not occur, pusis formed.The resulting abscess is limited by the fibrous
trabeculae to one or more of the fibro-fatty com-partments and involves only a portion of the pulpspace. As the abscess grows it spreads in one ormore of three directions :--(a) through theperiosteum to involve the terminal phalanx (oroccasionally round the side of the bone to presentas a' paronychia'); (b) through the skin in frontforming at first a collar-stud abscess under thehorny layer; (c) through the containing fibrouswalls at its sides to the rest of the pulp space (Fig.I). Usually the skin and periosteum give wayfirst, so that a skin sinus or an osteitis arises beforethe whole of the pulp space is involved. If leftuntreated the outcome of a pulp space abscessdepends therefore on its site. If superficial, askin sinus develops and by discharging the pus andslough, may lead to a spontaneous cure. Thedeeper abscesses and especially the more distal
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FIG. I.-The possible routes of spread of a pulp-spaceabscess.
ones, where there is less soft tissue cushion be-tvveen the skin and periosteum, are followed by an'early periosteal necrosis and osteitis. Necrosis ofthe whole of the pulp space, as evidenced byfluctuation, is a late stage and it may be assumedthat the phalanx is dead. In support of the abovepathology is the clinical fact that the spontaneousskin sinus and the earliest X-ray evidence ofphalangeal erosion always arise directly oppositethe site of the maximal abscess tension. Thus adistal pulp space abscess leads to an osteomyelitisat the tip of the phalanx, a proximal one to aninitial erosion at the base (Fig. 2). We do nothelieve that pressure occlusion or thrombosis ofbigital vessels plays a significant part in the naturaldistory of a pulp space infection.
Clinical DiagnosisThere are few clinical conditions which can be
confused with a pulp space infection. Gangreneof a single finger tip which is occasionally seen inarteriosclerotic patients is sometimes mistakenlyincised. The lack of tenseness and local heat,together with the general evidence of arterio-sclerosis should prevent this mishap.The diagnosis once made, it is important to
separate the simple felon (70 per cent.) from thegroup which already have an established bony·infection (30 per cent.). The latter may not beshown by X-ray at the first attendance at theclinic; clinical signs suggestive of bony infection·must therefore be relied upon. These are :-
(a) Previous inadequate incision; especiallycommon when performed under localethyl chloride.
(b) Spontaneous skin sinus formation. Thissign, first described by Klapp, is usuallyreliable.
(c) Massive soft tissue necrosis as demonstratedby 'bogginess' on palpation, 'club-shaped' pulp or direct operative findings.
(d) Post-operative pain.
TreatmentThe correct treatment of a pulp-space infection
is without doubt incision and drainage as soon aspus has formed. Less than 5 per cent. of casesseen by us were in the ' cellulitic' stage, whensplintage and rest together with chemotherapymay occasionally abort the abscess formation.Evidence of a local abscess is a throbbing pain andfocal tenderness and tenseness when tested by amatch-stick or probe.The first 400 cases seen were incised by a
lateral ' hockey-stick' incision. This we aban-doned because (a) it is common experience that apulp space abscess which has been widely openedthrough a lateral incision, will continue to drainthrough a tiny spontaneous skin sinus directlyoverlying it, whilst the lateral incision will sealoff; (b) on general surgical principles it seemedlogical that a local abscess should be drained by adirect incision rather than through a valve-likeslit, which opens up previously unaffected tissueand quickly closes by oedema; (c) we have beenimpressed by the number of ' persistent painfulstates ' which follow digital nerve injury especiallywhere sepsis is present. To avoid severing amajor digital nerve branch with a lateral incision ismore fortuitous than deliberate, whilst with thedirect incision the nerves are shouldered away bythe abscess and are not involved in the incision.
In the last 18 months we have used directincisions only.Technique of Direct Incision (Fig. 3)The site of the abscess must be accurately
localized prior to incision. If a collar-stud abscessor a skin sinus is present, the abscess cavity iseasily found. The finger must be completelyanaesthetized by a digital nerve block or a generalanaesthetic and the field rendered bloodless by afinger or arm tourniquet. An ellipse of thickenedhorny skin is excised over the abscess when athreatened or frank sinus is usually obvious in thecutis vera. This is incised for a few millimetres inthe long axis of the finger and the edges of theincision trimmed to expose the underlying abscesscavity. This is circumscribed and rarely more than
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FIG. 2.-Showing that the initial bony erosion isalways opposite the site of the soft tissueabscess.
a few millimetres in diameter. Apart from theevacuation of the pus and loose slough it is notdisturbed. The periosteum at its base is carefullyinspected for evidence of erosion. The cavity isfilled with penicillin in lactose powder and thefinger dressed with lightly impregnated vaselinegauze and an outer layer of absorptive dry gauze.No splint is needed, though a triangular sling for24 hours is normally advisable. Two or threesimilar dressings at two to three day intervalswill be sufficient, as the cavity is soon obliteratedand healing occurs.
The Value of Systemic Penicillin in PulpSpace InfectionsIn uncomplicated pulp space infections systemic
penicillin does not strikingly reduce the period ofdisability. It will, however, reduce the incidenceof complications and should be given whenlymphangitis, cellulitis, osteitis or arthritis arealready present. Barber (I947) has shown that thepercentage of penicillin-resistant staphylococcimay be increasing and this is certainly borne outby our recent experiences. With, such strainstopical streptomycin (2,000 units/cd.) has been ofvalue.
ResultsThe period of incapacity in a largeries of pulp
space infections in various clinics as been re-viewed recently by Barclay (I949). In our collec-tion the simple felon required an average of 17days for healing with lateral and about I2 dayswith direct incisions. The latter technique alsogives a better cosmetic result, a more painlessconvalescence and a lower incidence of post-incisional painful states. When a suspected orestablished osteitis or an arthritis is present asimilar surgical technique is used with the additionof systemic penicillin for Io to I4 days as an out-patient. These cases will heal in four to six weeks,with a partial or total reformation of the terminalphalanx. We do not recommend removal of theterminal phalanx either in whole or in part, unlessthere is clear X-ray evidence 6f sequestrationor avascular necrosis, both of which are un-Common.
AcuteSParonychia'The abscess usually starts on the deep aspect
of the nail fold and is at first hidden by the normaladhesion of the nail fold to the nail. It mayspread to the superficial aspect of the nail fold orunder the nail, but remains subcuticular ' (Pilcher,1948).Once the above pathology is understood, these
infections are not a problem. In the celluliticstage many settle with local rest and systemicpenicillin therapy. Where pus has formedunilateral or bilateral nail fold incisions will beneeded, and only the nail ' floating' free from itsbed should be removed (Fig. 4). Because of thesubcuticular site of the abscess, a skin sinus re-sults before an osteitis can develop in the un-treated case and complications are rare.A variant of the classical paronychial infection
is the chronic granuloma, called by Iselin abotryomycoma (Fig. 5). This apparently arisesfrom a low grade infection and is treated by awedge excision including its base. Application of
F
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266 POST GRADUATE MEDICAL JOURNAL, ,. June 1949...K
caustics or scraping is useless, the granulationtissue reformirul- surprisingly rapidly.Web Space Infection
This is a subcutaneous infection of the webspace which often extends to or spreads from theloose subcutaneous space on the palmar aspect ofthe proximal phalanx. It is normally accompaniedby considerable oedema over the dorsum of thehand and interdigital cleft and because of thismay be misinterpreted as a palmar space infection.
Anatomically, the infection lies in front of thesuperficial palmar ligament and is limited in itsmore proximal spread by the increasing adherenceof the skin to the palmar fascia. The web spaceinfection never spreads more deeply into thepalmar spaces, and the abscess points either inthe web space or on the palmar aspect of theproximal phalanx.When an abscess has formed it should be drained
through an incision sited directly over the pus.Thus for an anterior collection a transverse skincrease incision may be used or a cleft incision forthose pointing in the web space. A narrow ellipseof thick skin is excised, the abscess carefullyopened through the true skin and enlarged asnecessary to drain the cavity adequately, greatcare being taken to avoid the digital nerves andvessels. A small glove drain is left in for 24 hours.Immobilization and sometimes elevation will benecessary for two to three days. As soon as theoedema and pain have subsided, active fingerexercises should be instituted.
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FIG. 6.-The sites where phalangeal infectionstypically point.
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FIG. 7.-Erysipeloid of Rosenbach.
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FIG. 8.-Clinical and radiological appearance of inter-phalangeal arthritis.
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June i949 JEPSON and BOLTON: Modern Trends in the Treatment of Infections of the Hand 267
The large thenar web with its loose sub-cutaneous tissue causes most confusion in diagnosisand may closely imitate the true thenar space in-fection. In the former the pus does not lie infront of the adductor pollicis but in the lax tissueof the web itself. When this web abscess isdrained, care must be taken to avoid the aberrantradial artery, which may run in the space.
Phalangeal InfectionsThese are subcutaneous infections on the palmar
aspects of the middle and proximal phalanges.The abscess points in one of two places dependingon its original site (Fig. 6). It usually involves thesubcutaneous space of one phalanx only, but afew transgress the interphalangeal flexor crease.Treatment is by drainage of the abscess at thepoint of maximal tension, local application ofpenicillin powder and immobilization for 24 to36 hours. Complications are rare. Nerve andtendon injury may follow injudicious surgery.Tendon Sheath InfectionsExcluding the gross traumatic injuries these
mainly arise by (a) a perforating wound, often aminor prick, usually opposite the flexor creaseswhere the tendon sheath is closely bound to theskin; (b) as a sequel to a phalangeal infection;(c) due to an injudicious surgical incision.
Diagnosis. The diffusely swollen finger is heldimmobile and semi-flexed. Severe pain is ex-perienced on passive extension though the patientcan usually flex the finger painlessly through asmall range. The maximal tenderness is over theproximal cul-de-sac of the affected tendon sheath.
Treatment. All cases of tendon sheath infectionshould be admitted to hospital.
(a) Early cases. Within the first 24 to 48 hoursof onset, the majority of cases settlequickly on systemic penicillin-, oo,ooounits three hourly. The finger is splintedfor two days, then active movementscommenced.
(b) Late cases. In those cases which do notrespond quickly to intensive penicillintherapy or which are seen late and it issuspected that pus has formed in thetendon sheath, a small lateral incision ismade over the proximal phalanx and thesynovial sheath washed out with penicillinsolution using a fine plastic catheter. Noattempt is made to drain the sheath,although the small skin incision is leftopen. Active movements within thelimits of pain should be commenced after48 hours' splintage.
Results. These are now excellent in contrast tothe almost uniformly disastrous outcome in the
pre-penicillin era. Except when the tendon wasnecrotic, all our patients have recovered adequateor complete function.
Palmar Space.InfectionsTrue palmar space infections are uncommon
lesions. Hypothenar space infections should bedrained through a longitudinal Henry incisionalong the ulnar border of the hand, thenar in-fections by an anterior incision in Lange's linesand the introduction of forceps. The deep middlepalmar abscess necessitates the splitting of theweb between the third and fourth fingers. A pair-of forceps is then introduced to ensure drainage.Early active movements are imperative especiallyin the older age groups.Erysipeloid of Rosenbach (Fig. 7)This is an intra-epithelial erysipeloid of low
virulence and slow progression leading todesquamatiorr. It is important that it should bediagnosed correctly as surgery is contraindicated.A history of a prick whilst handling fish or swineis almost always obtainable and the condition iscommonly seen at hand clinics serving abattoirsand meat and fish markets. One of our casesabraded his thumb whilst dissecting an elephant.The infecting organism is erysipelothrix rhusio-pathiae. The skin is hot and purple-red and thepatient complains of a pricking or tight sensationbut no pain. The sharply-defined flat edge of theinfection advances slowly, rarely giving rise tolymphangitis. It has the peculiar characteristicof involving neighbouring fingers by spreading-distally from their base. Suppuration never occursand constitutional symptoms are slight or absent.The disease is self-limiting with a tendency torelapse. Serum and sulphonamides have beentried but the most useful therapy in our experiencehas been penicillin 200,0o00 units twice daily for atleast seven days. This seems to clear the in-fection and prevent relapse.Terminal Interphalangeal ArthritisThis should present no difficulty in diagnosis.
Cases fall into two groups, (a) when an uncon-trolled phalangeal osteitis following a pulp spaceinfection spreads proximally into the joint andsometimes beyond,. (b) following a paronychialinfection when it betrays itself by the extensivedorsal fusiform swelling which is always present(Fig. 8). Interphalangeal joint movement ispainful and restricted. The diagnosis may beclinched by X-ray and also by the following test.Clasping the middle and terminal phalanges, thesurfaces of the interphalangeal joint are gentlymoved over each other from side to side. Abnor-mal mobility and palpable fine crepitus are
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diagnostic. Treatment is by drainage of theoriginal lesion, splintage and systemic penicillintherapy for Io to I4 days. 'A considerable numberof joints so treated regain some useful movement.
Notes on Methods and ComplicationsPenicillin. This is most satisfactorily ad-
ministered in an out-patient organization by adaily injection of penicillin in a delayed absorptionmenstruum. Clinically one must be on theoutlook for the septic finger which does notrespond as expected whilst on penicillin therapy.'Bacteriological and penicillin sensitivity studiesshould be made in all severe hand infections as aroutine.
Streptomycin.-No supplies for parenteral ad-ministration are yet available. Where penicillin-resistant organisms are present and the degree ofinfection warrants its use, we have appliedstreptomycin locally in a concentration of 2,ooounits per cc. The technique is to cover the in--fected area with a layer of mesh tulle gras, onwhich is laid several thicknesses of gauze saturatedin streptomycin solution. This is covered withsterile oiled silk whose edges are sealed withmastisol. A single topical application of strepto-mycin retains its potency for about 48 hours, whichis usually sufficient to sterilize the surface of theinfected area.
Dressings. The dressings should be sterile,absorptive, painless and easily removed. A singlelayer of wide mesh tulle gras covered with steriledry gauze fulfils these criteria. Soaks, moistdressings and antiseptic baths encourage secondaryinfection and lead to swollen oedematous fingers,exaggerating the normal inflammatory oedema.
Sterile ribbon gauze impregnated with penicillincream is useful for large cavities. Penicillinpowder is made up with lactose powder to avoid'caking.' 'One-half per cent. brilliant green is auseful application in the end phase of many handinfections, where there is a superficial flat un-healed surface.
Physiotherapy. We do not use short-wavediathermy or infra-red irradiation as they meanfrequent disturbance of the dressings and the riskof secondary infection. Immobilization of afinger or hand by a copious dressing of cottonwool and a sling is usually sufficient without de-liberate splintage. This is maintained as long ascellulitis or lymphangitis'(9 per cent. of all cases)are present. Active mobilization of the fingerswithin the limits of pain is of paramount im-portance and patients should be encouraged andinstructed in hand exercises at the earliest moment.Movements are usually started 24 hoqrs afterincision and only supervised in the massage de-partment if the. patient shows hesitancy or slowprogress at follow-up visits.
Persistent painful states following digital nerveinjury. Similar cases have been described byHomans as' minor causalgias.' They present witheither spontaneous pain, cutaneous burning or adeep ache, or with a markedly lowered thresholdto mechanical stimuli. The affected finger iscold, blue and tapering. The milder varietieswhich have some tactile hyperpathia and 'coldache,' clear spontaneously aided by physiotherapyand wax baths. The severer'states are extremelytroublesome and require careful analysis beforetherapy can be instituted.
ACKNOWLEDGMENTSOur thanks are due to Professor A. M. Boyd
under whose supervision the study has been made,and to the radiological, pathological and physio-therapeutic departments of the Manchester RoyalInfirmary for their technical assistance.
BIBLIOGRAPHY
BARBER, M. (I947), Brit. Med. Y., 2, 863.BARCLAY, G. A. (I949), Brit. Med. J., x, 175.BOLTON, H CATCHPOLE, B. N., and JEPSON, R. P. (I947),Lancet, a,t6o8.HENRY, A. K. (I945), 'Extensile Exposure applied to Limb Sur-
gery,' E. & S. Livingstone Ltd., Edinburgh.HOMANS, J. (1940), New England J. of Medicine, 220, 870.KLAPP, quoted ISELIN, M. (1940), 'Surgery of the Hand,'
London.MOSS, B., et al. (I948), Lancet, I, 320.PILCHER, R. S. (1948), Lancet, a, 777.
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