Acute Paronychia
- ▪
Indication: Infection involving the nail fold, most common overall hand infection (usually Staphylococcus aureus ).
- ▪
Diagnostic Pearls: Of all the fingertip areas, the hyponychium is most resistant to infection. Carefully evaluate for infection residing in the nearby nail plate or distal pulp.
- ▪
Pitfalls: Misdiagnosis, delayed diagnosis, failure to identify underlying osteomyelitis.
- ▪
Surgical Pearls: Incise eponychial fold with nail blade faced away from matrix to avoid nail bed injury.
- ▪
Healing timelines and progression of therapy: Daily soaks in dilute povidone-iodine (Betadine) solution; 7- to 10-day course of oral antibiotics, early digit range of motion (ROM).
Felon
- ▪
Indication: Closed space infection manifested by a tense distal pulp with or without fluctuance.
- ▪
Pitfalls: Misdiagnosis, incomplete decompression of all involved septa, iatrogenic digital nerve or vessel injury, creation of unstable pulp.
- ▪
Surgical Pearls: Incision is dictated by the point of maximal tenderness and location of any fluctuance. Digital nerves and vessels at risk, avoid incisions that cross the flexion creases.
- ▪
Healing timelines and progression of therapy: Gauze wick for 48 to 72 hours, IV antibiotics for inpatients, Betadine soaks at least three times per day, early digit ROM.
Pyogenic Flexor Tenosynovitis
- ▪
Indication: Based on the four classic findings of Kanavel
- 1
Fusiform swelling of the digit
- 2
Semiflexed posture of the digit
- 3
Pain with passive extension of the digit
- 4
Tenderness along the flexor tendon sheath
- 1
- ▪
Pearls: Pain with palpation along flexor tendon sheath and with passive stretch are the most reliable clinical findings; early tenosynovitis may be treated with antibiotics, elevation, and frequent evaluation.
- ▪
Surgical Pearls: Early decompression is warranted if symptoms fail to resolve; operative management with sheath irrigation is effective. Irrigate until the effluent within the sheath is clear.
- ▪
Healing timelines and progression of therapy: IV antibiotics, repeat debridement if symptoms do not improve, soaks in Betadine solution, pain management to allow early digit ROM.
Fascial Space Infections
- ▪
Indications: Dorsal subcutaneous, dorsal subaponeurotic, hypothenar, thenar, and midpalmar space infections. Most are usually the result of penetrating trauma to the hand.
- ▪
Diagnostic Pearls: Deep space infections characterized by wide abduction of the digits, difficulty with motion, loss of palmar concavity, semi-flexed positioning and pain with passive stretch.
- ▪
Surgical Pearls: Separate dorsal and volar incisions should be utilized. Particular care should be taken to avoid the superficial palmar arch, digital neurovasculature, and deep palmar arch.
- ▪
Pitfalls: Delay in diagnosis, inadequate decompression, iatrogenic injury to digital neurovascular structures.
- ▪
Healing timelines and progression of therapy: IV antibiotics, repeat debridement if symptoms do not improve, soaks in Betadine solution, pain management to allow early digit ROM.
Since the discovery of penicillin in 1944 and the pioneering work of Dr. Allen Kanavel, the noted Chicago general surgeon who treated hand infections in the preantibiotic era (early 20th century), the incidence of hand infections has declined and the ability to recognize and treat these maladies has improved. Despite the advances of modern medical care, however, hand and wrist infections remain among the most disabling ailments affecting the upper extremity. Hand infections vary from routine problems treated with oral antibiotics, immobilization, and limited incision and drainage to catastrophic surgical emergencies resulting in significant deformity, pain, and loss of function.
A hand infection can predispose the individual to a lifetime of disability, which is why patients often require prolonged hospitalization and rehabilitation. In most cases, a hand infection begins with a minor penetrating trauma or small open wound.
Its character and progression are determined by several factors, including its specific location within the specialized tissues, the host environment, the virulence of the particular organism, and, importantly, the administration of timely, appropriate care. A key to minimizing the incidence and severity of hand infections is the prompt administration of treatment for even the most minor injuries. The purpose of this review chapter is to provide a systematic approach to the diagnosis, examination, evaluation, and treatment of both common and uncommon hand infections.
General Considerations
Injuries that break the skin barrier almost always create a wound contaminated by bacteria. Whether the microorganisms multiply and establish an infection is determined by both their virulence and the host’s immune response. Poor arterial blood supply, venous congestion, the presence of necrotic or damaged tissue, and the presence of foreign bodies are all local factors that increase the likelihood of infection. A patient’s resistance can be compromised by certain systemic conditions, the most common of which is diabetes mellitus, which affects 5% to 7% of the adult population of the United States. Other patient conditions include AIDS, Raynaud’s disease, agranulocytosis, severe chronic illness, immunosuppressive therapy, malnutrition, alcoholism, chronic steroid use, and drug abuse.
Although almost any type of microorganism can cause a hand infection, most cases involve Staphylococcus aureus (50% to 80%) and β-hemolytic streptococci (15%). The next most common pathogens are Aerobacter aerogenes (10%), Enterococcus (10%), and Escherichia coli (5%). Infections resulting from penetrating trauma usually involve a single species, but those associated with bites and IV drug use are polymicrobic in more than 50% of cases. Initial antibiotic therapy traditionally has been empirical, depending on the results of the Gram stain and the most likely organism. The emergence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has recently become a particularly relevant topic. Multiple studies have shown that the overall prevalence of MRSA ranges anywhere from 34% to 61% in the general population. With an increasing incidence of MRSA, health care providers should consider the use of initial antibiotic therapy targeted against MRSA with the aim of more quickly targeting the causative organism . Furthermore, the addition of antibiotics effective against gram-negative organisms has been recommended for high-risk situations, such as infections in IV drug abusers and contaminated outdoor or farm-related injuries. Tables 19-1 and 19-2 summarize the most commonly used antibiotics, antifungals, and antiviral agents used today.
| Class | Examples | Spectrum | Notes |
|---|---|---|---|
| Penicillins | |||
| Natural Penicillins | Penicillin G, penicillin V | Most streptococci, gram-positive anaerobes, some staphylococci; poor against gram-negative | Effective for Streptococcus viridans, Pasteurella in bite infections |
| Penicillinase-resistant | Nafcillin, methicillin, dicloxacillin | Similar to natural penicillins, but better Staphylococcus coverage | Nafcillin effective for septic arthritis and osteomyelitis |
| Extended-spectrum | Ampicillin, amoxicillin | Similar to natural penicillins, but better gram-negative coverage | |
| With β-lactamase inhibitors | Amoxicillin-clavulanate (Augmentin), ampicillin-sulbactam (Unasyn) | Similar to extended-spectrum penicillins, but better coverage of β-lactamase-producing staphylococci, gram-negative | Good first-line coverage for diabetic hand infections |
| Cephalosporins | |||
| First generation | Cephalexin (Keflex), cefazolin (Ancef, Kefzol) | Similar to penicillinase-resistant penicillins against gram-positive; some gram-negative | Recommended prophylaxis against wound infections |
| Second generation | Cefuroxime, cefotetan | Similar to penicillinase-resistant penicillins against gram-positive; more gram-negative | |
| Third generation | Ceftriaxone, ceftazidime | Similar to second generation but including Pseudomonas | Ceftriaxone effective against Gonococcus |
| Fourth generation | Cefepime | Similar to third generation | |
| Other β-lactams | |||
| Carbapenems | Imipenem, meropenem | Broad spectrum against most gram-positive and gram-negative bacteria, some Pseudomonas | Reserved for severe, polymicrobial infections |
| Monobactam | Aztreonam | Some gram-negative, no anaerobes or gram-positive cocci | |
| Glycopeptides | Vancomycin | Gram-positive, including MRSA; no gram-negative coverage | IV only, can cause red-man syndrome if infused quickly |
| Polypeptides | Bacitracin, polymyxin | Bacitracin covers only gram-positive, polymyxin covers only gram-negative | Topical use only |
| Aminoglycosides | Gentamicin, tobramycin, amikacin | Gram-negative, including Pseudomonas | Monitor levels, screen for nephrotoxicity, ototoxicity |
| Tetracyclines | Tetracycline, doxycycline | Most gram-positive, some gram-negative | Do not use in children (stains teeth, bones) |
| Macrolides | Erythromycin, clarithromycin | Most gram-positive, some gram-negative, clarithromycin active against mycobacteria | Gastrointestinal side effects common |
| Oxazolidinones | Linezolid (Zyvox) | All staphylococci (including MRSA), all streptococci, all enterococci (including VRE) | Good oral bioavailability, bone/joint penetration |
| Lincosamides | Clindamycin | Staphylococci, some gram-negative anaerobes | High incidence of gastrointestinal side effects |
| Streptogramins | Quinupristin, dalfopristin (Synercid) | Staphylococci, streptococci, enterococci (including VRE) | IV only, good bone/joint penetration |
| Fluoroquinolones | |||
| Broad-spectrum | Ciprofloxacin (Cipro), levofloxacin (Levaquin) | Broad gram-positive and gram-negative coverage | Good oral bioavailability for bone and joint infections |
| Expanded-spectrum | Gatifloxacin (Tequin), moxifloxacin (Avelox) | Similar to broad-spectrum fluoroquinolones, but better gram-positive coverage | Good oral bioavailability, limited FDA approval |
| Metronidazole | Metronidazole (Flagyl) | Parasites, anaerobes including Clostridium difficile | Drug of choice for C. difficile |
| Sulfonamides | Trimethoprim-sulfamethoxazole (Bactrim) | Broad range of gram-positive, gram-negative | Commonly used for urinary tract infections |
| Antimycobacterials | Isoniazid (INH), ethambutol, cycloserine, rifampin, pyrazinamide (PZA) | Mycobacteria; rifampin also effective against gram-positive cocci | Usually used in combinations; consult infectious disease specialist |
| Class | Examples | Spectrum | Notes |
|---|---|---|---|
| Antifungal Agents | |||
| Polyenes | Amphotericin B, nystatin | Most fungi | Liposomal preparation amphotericin B has reduced nephrotoxicity |
| Azoles | Ketoconazole (Nizoral), fluconazole (Diflucan), itraconazole (Sporanox) | Most fungi | Systemic use well tolerated |
| Nucleoside analogues | 5-Fluorocytosine | Candida, Cryptococcus, Aspergillus | Resistance develops rapidly |
| Allylamines | Terbinafine (Lamisil), naftifine (Naftin) | Most fungi, dermatophytes, no yeast | Terbinafine is the systemic drug of choice for onychomycosis |
| Grisans | Griseofulvin | Dermatophytes, no Candida | Incorporates into hair, nails when taken systemically |
| Antiviral Agents | |||
| Nucleoside analogues | Acyclovir (Zovirax), valacyclovir (Valtrex), ribavirin (Virazole), ganciclovir (Cytovene), fluorouracil | Herpes, varicella-zoster, influenza (ribavirin only), hepatitis C (ribavirin only), cytomegalovirus (ganciclovir only), human papillomavirus (topical fluorouracil) | Acyclovir, valacyclovir can be used for herpetic whitlow treatment and prophylaxis; ribavirin and interferon can be used for postexposure prophylaxis against hepatitis C; topical fluorouracil can be used for hand warts |
| Antiretrovirals; reverse transcriptase inhibitors | Azidothymidine (zidovudine, AZT, Retrovir), didanosine (Videx), lamivudine (Epivir), stavudine (Zerit) | HIV | AZT is the most commonly used antiretroviral, can be used for postexposure prophylaxis |
| Protease inhibitors | Indinavir (Crixivan), nelfinavir (Viracept) | HIV | Often used with AZT and other reverse transcriptase inhibitors |
| Anti-influenza drugs | Amantadine, zanamivir (Relenza), oseltamivir (Tamiflu) | Influenza A, influenza B (zanamivir and oseltamivir only) | Can reduce length of flu if taken within 48 h of infection |
| Interferon | Interferon-α | Hepatitis A, B, C; herpes; papillomavirus | Combined with ribavirin for hepatitis postexposure prophylaxis |
Anatomy
A thorough understanding of the hand’s specialized anatomy is crucial in determining the ease of penetration, localization, and spread of infection. An appreciation for the intricate anatomy of the hand also allows for precise surgical exploration and drainage without injuring vital structures or extending the infection to uninvolved tissues. The skin, subcutaneous tissue, tendon sheaths, and joint spaces are some of the specialized structures in the hand, and their anatomy is addressed elsewhere in this text. The fascial spaces and lymphatics are other important components of the hand’s anatomy and merit a brief review at this time.
The hand contains five fascial spaces in which pus can accumulate: (1) dorsal subcutaneous, (2) dorsal subaponeurotic, (3) hypothenar, (4) thenar, and (5) midpalmar ( Fig. 19-1 ). Other spaces that provide an optimal environment for the rapid growth of microorganisms include the flexor tendon sheaths and the joint spaces, which contain synovial fluid and are lined with a specialized layer of synovial tissue. Infections within the synovial spaces are among the most devastating of all hand disorders.
The lymphatics of the hand can be classified into two types according to their origin and location. The superficial lymphatics arise in the skin and course through the subcutaneous tissue, and the deep lymphatics arise in deeper tissue and follow the blood vessels. The lymph vessels in the fingers follow the digital arteries and are most abundant on the volar surface. From this point, the channels flow dorsally in the interdigital spaces along the medial and lateral borders of the hand and then travel proximally up the dorsal surface. This anatomic pathway explains how a primary infection in the palmar surface can initially present with dorsal swelling.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
