A 38-year-old diabetic man presents with worsening pain and swelling of his left ring finger (▶Fig. 54.1). About 5 days ago, he sustained a small laceration on the volar surface when he was working with a screwdriver in his garage. Two days ago, he was seen in a minor emergency center and had drainage of a small “superficial” abscess on the volar surface of this finger by the ER physician. He was started on oral cephalosporins and he was told to soak this.
The patient presents with a serious infection of the hand after an inadequate incision and drainage. He appears to have flexor tenosynovitis as well as an abscess on the dorsal hand, the so-called collar button abscess. Inadequate treatment of the infection in the face of his diabetes has led to marked progression of the infection.
Early on with flexor tenosynovitis, there may not be obvious purulent drainage but on minimal palpation, purulence can sometimes be expressed. The septations that form separate abscess pockets can fool the surgeon into thinking that all the infection has been drained when it is actually just lurking nearby.
The most important anatomical consideration in this case is the presence of bursae and potential spaces in the hand that must be taken into account. The ulnar and radial bursae have an important connection in the forearm, which is called Parona’s space. This potential space lies between pronator quadratus and flexor digitorum profundus and can result in a “horseshoe abscess” that tracts from the small finger tendon sheath connecting to the thumb flexor tendon sheath. The deep thenar space and the mid-palmar space also should be taken into account. This patient appears to have extension of the abscess to the dorsal hand in the loose tissues of the web space and was found at surgery to have extension of the abscess into the distal forearm in the region of Parona’s space.
When bacteria inoculate the tendon sheath, the pressure can rise above 30 mm Hg. High pressures then obstruct the arterial flow to the tendon sheath. The effects of poor blood flow are twofold. One, inflammatory cells and antibiotics are unable to get to the infection and fight it adequately. Second tendon ischemia and necrosis result in long-term damage. Dead tissue mixed with synovial fluid that is devoid of white blood cells is an ideal breeding ground for bacteria and further long-term damage. If the patient and extremity survive the infection, then the hand surgeon will be left with a nonviable tendon and muscle that must be debrided. Eventually the surgeon must come up with a plan to make that extremity as functional as possible.
The problems that need to be fixed include adequate drainage of the infection (through debridement of nonviable tissue), skin coverage, and function of the hand. All of those will be addressed operatively.
• Debridement of nonvital tissues.
• Reconstruction of the complex soft-tissue defect.
The patient is taken to the operating theater and put under general anesthesia. A tourniquet is applied and a povidone–iodine prep is done. The arm should be elevated for exsanguination instead of an elastic bandage to prevent spreading of the infection more proximally. The tourniquet is inflated.