Hand Infections

Overview
Cellulitis Paronychia/eponychia Felon Herpetic Whitlow Flexor tenosynovitis

Deep fascial space infections Septic arthritis Osteomyelitis Fight Bites

Cellulitis of the hand

Involves only the skin erythema, edema, pain of localized area MUST document that deeper structures are not involved- beware the dorsal hand cellulitis!
Full painless ROM of digits, hand, wrist No tenderness on palpation of deeper structures

Strep pyogenes
Occasionally S. aureus

Cellulitis of the Hand

Treatment
Immobilize Elevate Antibiotics Keflex, Augmentin, Diclox

Disposition
D/c home with 24 h follow up unless
Immunocompromised Systemically ill Rapidly spreading

Paronychia
Localized superficial infection or abcess of the lateral nail fold Most common infection in the hand Caused by frequent trauma to area Swelling and tenderness of the soft tissue next to the nail fold May have associated cellulitis

Paronychia
If extends to overlying proximal nail: eponychia S. aureus
Thumb sucking/nail biting anaerobes Chronic candida

Treatment
Early Cellulitis
Soaks, elevation, antibiotics (Keflex)

Paronychia
Fluctuant all of the above, plus
Drain
May need anesthesia (digital block) Soften by soaking 11 blade If severe infection with purulent drainage beneath nail, requires removal of a portion of the nail

Follow up 24-48 h. Most resolve in 5-10 days

Paronychia
Complication
Osteo of distal phalanx
Refer to a hand surgeon..

Felon
Infection of the pulp of the distal finger or thumb Septa
Facilitate infection Inhibit drainage
BUT

Act as a barrier protecting the joint space and tendon sheathlimits proximal spread

Felon
Caused by penetrating trauma and secondary infection S. aureus Area of cellulitis and inflammation rapidly progresses to severe throbbing, pain, redness, swelling, tense feeling of distal finger

Felon
Treatment
Early and complete incision through septa Digital block Most drained by single lateral incision with blunt dissection, also volar approach Send cultures Irrigate, dress, elevate Reevaluate in 24-48 hours Antibiotics anti-staph for 7-10 days

Felon
Complications
Osteo Necrosis of palmar surface and formation of sinus tract Septic arthritis Flexor tenosynovitis

Herpetic Whitlow
HSV infection of distal finger Either type Most common viral infection of the hand Caused by direct inoculation through broken skin
Kids with herpetic gingivostomatitis Adults more likely HSV 2 Health care workers

Herpetic Whitlow
Single finger Pain, pruritis swelling Vesicles Coalescence over 2 weeks Ulcer formation Hemorrhagic base May look like a felon but DRAINAGE IS CONTRAINDICATED!!

Herpetic Whitlow
Take a careful history Tender distal finger but SOFT pulp space Clinical diagnosis Resolves spontaneously in 3-4 weeks
Prevent oral inoculation by covering with a dry dressing

Acyclovir only if immunocompromised or frequent infections

Flexor tenosynovitis
This is a surgical emergency act quickly to preserve function of digit and hand Usually involves flexor tendon sheaths and radial and ulnar bursae

Flexor tenosynovitis
Infection spreads along course of flexor tendon sheaths, may spread to midpalmar, thenar, lumbrical compartments Caused by penetrating trauma to sheath Consider disseminated GC if no trauma, sexually active S. aureus
Also strep, anerobes, gram neg

Flexor Tenosynovitis
Clinical features
Tenderness along course of tendon Symmetric swelling of the finger Pain on passive extension Flexed posture of finger

Flexor Tenosynovitis
Treatment
Splint and elevate Amp/Sulb or Cefazolin and a PCN Consider Vancomycin if IVDA Consider Ceftriaxone if concern of disseminated gonococcal infection ADMIT AND HAND CONSULT

Deep fascial space infection

Palm is relatively fixedthe dorsum will show the infection Beware the dorsal hand cellulitis! 4 potential spaces
Dorsal subaponeurotic space Subfacial web space Thenar space Midpalmar space

Deep fascial space infection

Infection from
Direct penetrating trauma Contiguous spread Hematogenous spread

S. aureus, strep, occ. coliforms and anaerobes

Deep Fascial Space Infections

Dorsal subaponeurotic abcess
Swelling and erythema on dorsum of hand Pain with passive movement of extensor tendons Looks like cellulitis

Subfacial web space infection

Secondary to infection of palmar blisters Spreads dorsally - collar button abcess

Deep Fascial Space Infection

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

Deep fascial space infection

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
Any joint From direct inoculation from penetrating trauma or contiguous spread S. aureus (rarely others) Nontraumatic? Think GC. Joint is red, swollen, tender, localized (unlike flexor tenosynovitis) May have overlying puncture wound

Septic Arthritis
Held in position to maximize joint volume Very painful passive flexion, axial load Diagnose by arthrocentesis Treatment
Antibiotics to cover staph Hand consult for open drainage in OR

Osteomyelitis
Most common with open fractures or soft tissue infections Fever, redness, swelling, warmth, tenderness, pseudoparalysis (in kids) Plain film bony destruction or periosteal elevation Treatment
Antibiotics (long term) Debridement

Fight Bites
Incisor + oral flora + many tissue layers = rapidly spreading infection Physical exam puncture wound, area of cellulitis surrounding. Tendon maybe visible inside the wound. Plain film is indicated often associated with fractures

Fight Bites
Treatment
Antibiotics to cover Strep, Staph, Anaerobes, Eikenella, Neisseria
Amp/Sulb

Clean and irrigate throroughly Leave open Immobilize Elevate Hand consult