Hand infections

Management of acute infections of the hand by Dr Vivek Singh AIIMS R

1. Hand infections Dr Vivek Singh 23/4/2017

2. Nail Anatomy

3. Paronychia Infection of the lateral nail fold Most common Eponychia Run-around infection

4. Paronychia Staph aureus most common although most are mixed V iolation of the seal between nail plate and nail fold Risk Factors Hangnails, Manicures, Penetrating trauma, Constant exposure to a wet environment , Nail biting or sucking

5. Paronychia-Clinical presentation

6. Paronychia Laboratory evaluation if not responding to initial treatment Radiographs if long-standing infection, foreign body or osteomyelitis

7. Paronychia -Treatment Early stage Oral antibiotics, Warm soaks in Povidone-iodine Rest and observation Surgical decompression K eep blade away from nail bed A small wick is placed for 24 to 48 hours

8. Paronychia -Treatment Infection that travels below the nail plate - remove a portion of the nail. If the entire nail matrix is involved,then the entire nail is removed.

9. Chronic Paronychia Indurated , painful eponychium Frequent water immersion-predisposing Intermittent acute infections Diabetes and psoriasis predisposing Gram- positive,negative , Candida ,mycobacterial

10. Chronic Paronychia Marsupialization Nail removal if deformed Protect the germinal matrix Oral antibiotics for 2 weeks Change if Mycobacterial Early finger ROM

11. Felon Deep space infection of the distal pulp Differs from apical infections Multiple septal compartments Most frequent S. Aureus 15 % to 20% of all hand infections.

12. Felon P enetrating trauma Hematogenous spread Finger stick felon Most common in thumb & index finger. Throbbing pain Tense swelling localized to the pulp

13. Felon Extend toward the phalanx --> osteomyelitis Toward the skin --> draining sinus Obliterate vessels ---> skin slough or necrosis Suppurative flexor tenosynovitis S eptic arthritis of the DIPJ

14. Felon-Treatment Aim-Preserving the function of distal phalanx. Don’t wait for fluctuation if tension is severe If recognized early (mild cellulitis): soaks & antibiotics Abscess(48 hrs ): surgical drainage

15. Felon-Treatment Principles Avoid injury to nerve and vessels Don’t leave a disabling scar Do not violate flexor sheath Produce adequate drainage Keep wound open

16. Pyogenic Flexor T enosynovitis Synovial sheath Extend from the mid-palmar crease to the DIPJ (A1 to A5) S mall finger-Ulnar bursa Thumb sheath-Radial Bursa Parona space

17. Pyogenic Flexor Tenosynovitis Penetrating trauma Felons can rupture Purulence destroys the gliding mechanism Tendon necrosis possible Usual causative agent: Staph. Aureus Pasteurella multocida -animal bites. Immunocompromised -Mixed gram –and+

18. Kanavel’s 4 cardinal signs Severe pain on passive extension of the finger (most reliable) Kanavel  A:  Infections of the Hand .  7th ed. Philadelphia, Lea & Febiger , 1939.

19. Pyogenic Flexor Tenosynovitis-Treatment Early infection < 48 hrs - IV Abx , splinting & elevation Failure to respond within 24 hr -drainage Established pyogenic tenosynovitis is a surgical emergency

20. Treatment 2 basic approaches: Open vs. Closed

21. Closed tendon sheath irrigation

22. Deep Space Infections Hand-three potential palmar spaces. F orearm has one potential space. Hand-three superficial spaces

23. Deep Space Infections Swelling particularly on the dorsal side. Distinguish from local dorsal abscess X-Ray for retained foreign body, OM, or fracture. Aspiration, ultrasound, or MRI may be useful .

24. Thenar Space Infections

25. Thenar Space Infections Most common of deep space infection Cause-Penetrating injury Thumb or index subcutaneous abscess Thumb or index flexor tenosynovitis Extension from radial bursa or midpalmar space

26. Thenar Space Infections Marked swelling Thumb forced into abduction Severe pain with extension or opposition Infection tracks dorsally -Dumbbell or Pantaloon abscess

27. Thenar Space Infections- Treatment Treat as a surgical emergency Drain via volar or dorsal incisions or both Identify neurovascular structures Irrigate & debride Close over drain Compressive dressing & plaster splint

28. Midpalmar Space Infections

29. Midpalmar Space Infections Direct penetrating trauma, Rupture of septic tenosynovitis Loss of palmar concavity, Dorsal swelling, Pain on passive extension

30. Midpalmar Space Infections- Treatment

31. Deep Subfascial Space Infections Dorsal subcutaneous space Dorsal subaponeurotic space Interdigital web space-collar-button abscess

32. Deep Subfascial Space Infections Dorsal Subcutaneous and Dorsal Subaponeurotic Space Abscess P enetrating injuries D orsal aspect of the hand swollen,warm and tender. Finger extension difficult and painful. Differentiating from cellulitis or other hand infections difficult

33. Deep Subfascial Space Infections Web Space Abscess (Collar-Button Abscess) Hourglass shape Cause-fissure in the skin between the fingers P ain and swelling localized to the web space Swelling either palmar or dorsal aspect Finger abduction

34. Deep Subfascial Space Infections- Treatment Dorsal Subcutaneous and Subaponeurotic Space Abscess One or two dorsal longitudinal incisions Determine whether infection is superficial or deep Subaponeurotic space opened by incising along margin of the extensor tendon

35. Deep Subfascial Space Infections Collar-Button Abscess M ost important aspect-Treat both dorsal and volar components B oth dorsal and volar incisions

36. Deep space infections- Aftertreatment Keep wounds open Gauze wick for 48-72 hrs After 72 hrs soaks in Povidone -iodine IV Antibiotics 10 days Oral antibiotics 4 weeks Early active motion

37. Summary Careful history & examination Anatomical area involved Extent of spread Empiric antibiotics till culture report Prompt and adequate surgical treatment Immobilization in position of function Rehabilitation

38. Thank you