Antibiotic use.

Once the diagnosis is established, antibiotic use is an essential measure and should last at least for 1 week. Progression of the infection should be monitored closely.

Incision and drainage.

If there is suspicion of abscess formation, surgical incision and drainage are necessary. Paronychia, felon, and flexor tenosynovitis are perhaps the most common hand infections that need surgical incision and drainage. In the early stage of these infections, antibiotics are effective for most patients. Surgical incision at this early stage is not indicated, as there is no fluid or pus to drain. Days later, if the infection becomes progressively severe, presenting fluctuation of the site of infection (in patients with paronychia or felon) or prominent swelling (in patients with flexor tenosynovitis or deep infection), surgical incision, and drainage become necessary. Fluctuation in the infected area indicates pus formation, needing incision and drainage.

Penrose drainage and continuing antibiotic use.

Antibiotic use should be continued after incision and drainage for 1 or 2 weeks depending on the severity of the infections. A Penrose drain (a soft rubber tube for drainage) should be placed for the patient with flexor tenosynovitis or deep infection. Severe infections may need repeated surgical drainage. Because inflammation and swelling of the tissues persist for about a week during recovery from infections, swelling alone does not dictate repeated drainage. Repeated surgical drainage should be carried out only if there is a high likelihood of further abscess formation.

Causal pathogens and proper selection of antibiotics.

Microorganisms that can cause hand infections include bacteria, viruses, and fungi. The most common bacteria responsible for hand infections are Staphylococcus aureus , Streptococcus pyogenes, and gram-negative bacteria such as Escherichia coli and Pseudomonas aeruginosa . Methicillin-resistant Staphylococcus aureus (MRSA) is a strain that causes infections in different parts of the body. It is associated with both hospital- and community-acquired infections (HA-MRSA and CA-MRSA). It is tougher to treat because it is resistant to some often used antibiotics. Hand infections can also be caused by uncommon bacteria, such as Mycobacterium tuberculosis or atypical mycobacteria. The latter are typically insidious with long incubation and late diagnosis.

Bacillus anthracis is a rare cause of infection that causes cutaneous anthrax in the hands. Inhaled anthrax may be lethal, but cutaneous infections are easily managed with penicillin. Streptococcus pyogenes and Clostridium perfringens are known to cause devastating necrotizing fasciitis and gas gangrene.

Viral infections, such as herpes simplex virus, human papilloma virus, and even cowpox or parapox, cause hand infections (herpes, warts, and pox), especially in immunocompromised individuals. Fungal infections of the hand, mostly with Candida and Aspergillus species, are less common but may occur in individuals with weakened immune systems or those who work in wet or humid environments. Most are superficial, often of the nail complex, but deep infections can occur, resulting in serious clinical problems.

Supporting measures.

Patients with severe or prolonged infections need systemic nutritional and rehabilitation supports. Wound care, care from internal medicine, and rehabilitation should be included in the plan. Infectious disease and therapy teams are often involved.

Cellulitis.

Cellulitis is a general soft tissue infection, often originating from a wound to hand and digits ( Box 2.1 ). It can be associated with lymphangitis and sepsis. Antibiotic treatment, usually with a narrow-spectrum penicillin, is necessary and mostly sufficient. Surgery is hardly ever indicated, unless complications such as abscess arise.

Another common finger infection is a paronychia , an infection of the skin around the nail. It can occur as a result of a hangnail, cuticle damage, or other injury to the skin of the nail fold. Nail biting increases the incidence. The clinical presentation can be acute or chronic. Symptoms of acute paronychia include redness, swelling, and pain around the nail and, in some cases, pus develops, forming a characteristic horseshoe-shaped abscess under the skin of the nail fold ( Box 2.1 ).

Treatment of paronychia is usually with local antiseptic measures and with small incisions if there is abscess formation. Commonly, blunt dissection under the lateral nail fold can release and drain the underlying purulence if the infection is very localized. When infection involves entire nail folds, the proximal nail folds are released bilaterally, with the eponychium held open with strip gauze to help drainage. If necessary, the nail can be cut longitudinally with scissors or scalpel through its length, roughly one-third or one-half the width of the nail, on the affected side, and dissected free from matrix and proximal nail fold, releasing the underlying purulence. Soaking the incised digit with warm water, or 1:1 mix of peroxide and warm water, or betadine-saline solution a few times a day.

Another finger infection is the felon , which is an infection of the pulp of the fingertip ( Fig. 2.2 ). Felons can be caused by puncture wounds, cuts, or other injuries to the fingertip. Symptoms are severe pain, redness, and swelling of the fingertip, and an abscess may develop ( Box 2.1 ). Once an abscess has developed, surgical treatment is required to avoid progression, with loss of the fingertip, flexor tendon infection, and even life-threatening complications such as sepsis.

(A) A felon of the ring finger. (B) The radiologic findings. The Kanavel signs were negative, so the treating doctors excluded flexor tenosynovitis. (C) The diagnosis of a felon was made on the basis that the pulp of the fingertip was very painful. Recovery was full after emergency midline pulp incision and drainage.

Treatment of felon consists of surgical incision and drainage of the infected pulp and use of antibiotics ( Fig. 2.2 ). A longitudinal midline incision in the pulp is commonly used as this incision minimally interferes with the digital nerves and sensation of the fingertip. The incision should be deep (0.5–0.8 cm) to allow adequate drainage. The goal of surgical treatment is to completely release the internal septations within the volar pulp and debride any necrotic tissue. It is also popular to use a lateral longitudinal incision of the pulp through which the all septa are cut open; the depth of this incision usually is over 1 cm, reaching most of the pulp width. This incision causes little damage to sensory nerve fibers, and decompresses and drains all involved septa. The softened distal phalanx can also be debrided. However, it is advised not to remove excessive amount of fat from the pulp tissue because this can lead to a thin, hypersensitive and painful finger or thumb tip. After surgery, the incision is left open or packed with strip gauzes for further drainage. The incision usually heals by itself several days after drainage of the felon is completed. Most felons recover in several weeks. Complications include recurrence, nail deformity, pulp instability, and hypersensitivity.

Flexor tendon infections (i.e., flexor tenosynovitis , or pyogenic flexor tenosynovitis) of the hand are more serious conditions, that are closed-space infection inside the digital flexor sheath ( Figs. 2.3 and 2.4 ). Many patients present with a history of penetrating trauma. A small puncture wound can inoculate the flexor sheath space. Sometimes the disease cause is unclear. The diagnosis is based on the history and on physical examination, with swelling of the infected digit, tenderness of the digit and distal palm, limited digital motion, and palpable increase in pressure in the swollen digit ( Box 2.1 ). The four signs in a typical case are commonly found: (1) tenderness along the length of the affected tendon, (2) symmetric enlargement of the involved digital part or entire digit (fusiform swelling of the digit, or discribed as a sausage digit), (3) flexed posture of the digit, and (4) pain on passive digital extension and flexion of the digit. These signs differentiate it from other infections of the digit. The first three signs are classically called Kanavel signs, but all these signs can called so now. A typical case is not always seen, as early antibiotic use prevents the patient from typical manifestations.

(A) A patient who worked with primates presented with swelling of the left hand and acute carpal tunnel syndrome. (B) Flexor tenosynovitis with median nerve compression was visualized on MRI. (C) The complaints recurred 6 months after carpal tunnel decompression with increasing swelling of the distal volar forearm and wrist. Biopsies demonstrated granulomas, and nontuberculosis Mycobacterium kansasii was isolated on tissue culture. The patient was successfully treated with rifampin, ethambutol, and isoniazid plus pyridoxine for 12 months.

Incision and drainage of the finger with flexor tenosynovitis. The Penrose drain is left in place for 2 to 3 days to help drainage after surgical incision and irrigation.

Flexor tendon infections are a clinical diagnosis, which does not need imaging studies. X-rays, MRI, and ultrasound may sometimes be used to determine the extent of the infection. If diagnosis is within 24 hours after onset of symptoms, administering antibiotics and immobilizing the hand in elevation to reduce swelling may be attempted. In the patient with less severe infection, systemic use of antibiotic is effective; infection may subside 1 or 2 days later. In the patient with severe infection, surgical incision and drainage are necessary to open the tendon sheath and wash it out. The decision to operate or have conservative treatment is based on the duration and severity of symptoms and the extent of swelling on clinical examination and responses to the antibiotic use. In patients requiring incision and drainage, different incisions can be made: (1) midlateral long incision of the finger. (2) Bruner incision. (3) limited midlateral incision with opening of the sheath distal to the A4 pulley only. The proximal sheath is opened in the distal palm, and a catheter is placed to irrigate the sheath during surgery. (4) separate incisions are often made in the digit and at the distal palm, leaving a tissue bridge intact. These incisions can sufficiently allow irrigation and drain pus, but the A2 pulley (or a part of this pulley) and a skin bridge at the base of the digit are preserved, with a Penrose drain being placed under the skin bridge to help drainage for 2 to 3 days ( Fig. 2.4 ). If the infection extends distally to the finger, the incision is extended distally in the finger, but the A4 pulley should be kept intact. Separate shorter incisions allow sufficient washout and drainage. Postoperatively the incisions are left open entirely or loosely sutured. Soaking the finger in warm water a few times a day may help further drainage.

Late complications of flexor tendon infections include tendon adhesions, which may need tenolysis after infection is controlled. Digital stiffness often occurs, so early motion is highly recommended. Tissue necrosis may happen, needing debridement. Severely infected digits with joint stiffness or tendon necrosis may require amputation.

Abscess and deep space infections.

If any hand infections are left untreated, progression to abscess formation is a likely and feared complication. Hand infections may develop symptoms of acute carpal tunnel syndrome due to secondary compression by swelling. The individual separate compartments, or “deep spaces” (thenar, hypothenar, deep palmar, and web spaces), of the hand can become infected, sometimes from a small puncture wound, and care must be taken to evaluate all of the compartments in such injuries. As the infection spreads, the fingers become immobile, and there may be difficulty moving them.

The deep space infections occur in some confined tissue spaces, such as radial bursa, ulnar bursa, thenar space, midpalmar space, and hypothenar space. Infections of the radial or ulnar bursa are often accompanied by infection in the digits. Accumulation of pus does not occur within the bursa, but spread to the nearby tissue spaces. Horseshoe abscess may form when the infection spreads to the opposite border digit of the hand. Because interconnection of the digital sheath to these bursa may exist, when flexor sheath infections are diagnosed, the palm needs to be examined as well. Parona space is a the deep space in the distal volar forearm between the fascia of the pronator quadratus muscle and the FDP tendons. This space is in continuity with the midpalmar space. Therefore infection in the hand may spread to the forearm.

Infections of these spaces may occur in isolation after penetrating trauma, but often as a part of pyogenic flexor tenosynovitis, most commonly of the thumb or the little finger.

A deep space infection in the hand presents with pain, swelling, and tenderness in the thenar, mid-palmar, or hypothenar spaces. The area may also become discolored, sensitive to touch. The center of the infection may have a soft spot, where pus is forming. Both thenar and midpalmar space infections often present with swelling of the entire hand, but more remarkable swelling is on the dorsal aspect of the hand. The tight fascia on the palmar surface of the hand limits volar swelling. These infections are uncommon now because of early treatment with antibiotics.

Web space abscess (collar-button abscess) refers to the hourglass-shaped abscess in the web space. The pain and swelling is limited in the web space and distal area of the palm. The adjacent fingers are abducted from each other. The swelling can present on either the palmar or dorsal aspect, or both.

Treatment involves administering antibiotics and draining the abscess, and the incisions are left open for drainage. Extensive surgery, opening all involved compartments, may be necessary ( Box 2.1 ). If left untreated, hand abscesses can lead to serious complications, including permanent damage to the affected hand, spreading into the forearm, amputation, and septicemia.

In any serious infection of the hand, consideration must be taken to excluding a possible compartment syndrome of the hand, particularly of the intrinsic muscles ( Fig. 2.5 ). Surgical decompression is needed if the compartment of the hand is found to have great pressure with remarkable hand swelling, which may reduce the pain of the infected hand and avoid the necrosis and contracture of the intrinsic muscles.

Palmar (A) and dorsal (B) views of the hand after intrinsic compartment release after a high-pressure injection injury with an oily substance. Full recovery was achieved without contracture after multiple debridements.

Involvement of bones and joints in infection.

Involvement of the skeleton in hand infections may occur. Although osteomyelitis is uncommon in the hand and digital bones, septic arthritis of the hand takes second place in prevalence only to this problem in the knee joint. A sample of the bone taken from a contaminated wound often grows bacteria in culture, which is a result of wound contamination often leading to overdiagnosis of bone involvement. Furthermore, bone involvement does not equal osteomyelitis. Septic arthritis occurs more often and needs great attention. Where there is high suspicion of septic arthritis, needle aspiration or open exploration is indicated ( Box 2.1 ). For the joints, especially the carpal or radiocarpal joints, thorough debridement and systemic, targeted antibiotic treatment for a long period (often 6 weeks) are required to avoid long-term complications such as pain, stiffness, degenerative arthritis, osteolysis, and recurrent infections.

A number of senior hand surgeons with an orthopedic training background, including Joseph Dias and Jin Bo Tang focus attention on possible overdiagnosis of osteomyelitis in bones of the hand resulting in avoidable bone debridement.

In the bones in the hand, after open injuries, contamination is common, and soft tissue infection adjacent to bones contaminate the area and can produce a bacterial growth from a bony sample. This could lead to a wrong diagnosis of “osteomyelitis”.

Osteomyelitis typically occurs in long bones, with blood supply bringing pathogens to the cavities of the that bone, causing infection within bone marrow spaces. Osteomyelitis is typically a chronic infection of these bones. In the initial weeks radiographs can be normal but gradually the radiograph demonstrates sclerosis and patchy porosis of the cortex and medulla of the involved bone. Osteomyelitis is uncommon in bones of the hand partly explained by the smaller size and the good blood supply.

Once “osteomyelitis” in the hand is wrongly diagnosed, it can lead surgeons to offer resection or aggressive debridement of these bones, even though a more conservative procedure could result in infection control and preservation of the hand skeleton, reducing loss of function and a prolonged period of disability.

Only when there is radiographic evidence of bone necrosis in the phalanges or metacarpal bones, is surgical debridement of these necrotic bones indicated. MRI is very sensitive in identifying periosteal reactions but can cause false positive for osteomyelitis. MRI will alert surgeons to the possible diagnosis of osteomyelitis and the surgeons should make a clinical judgement whether that exists. Bones without signs of necrosis should not be resected.

Inappropriate radical debridement surgery causes functional loss due to bony resection. Many of us have encountered patients with simple common open fractures with local soft tissue contamination who have had possibly avoidable aggressive debridement of the bones of the hand.

Experienced surgeons exercise care and avoid unnecessary surgery and thereby avoid creating a greater clinical problem. We should not resect or aggressively debride bones if only their surface is contaminated or infected as skeletal support is critical for hand function. Resection of articular surface should be avoided for joint function. In short, avoid bony resection unless the bone is necrotic.

For any soft tissue infection in the hand, presence of abscess is a surgical indication. Clearly the first step is to drain abscess, remove necrotic tissue and leave the wound open followed by appropriate antibiotics based on the culture. It is important to give this process some time for natural healing and recovery as infection does not resolve immediately after debridement. It usually takes 3–5 days to improve clinically. Aggressive repeated debridement (such as every day) of a wound in the healing process delays the healing and recovery, increasing medical burden and cost.

Bite injuries.

Bite injuries are notorious for causing complicated infections. Animal bites are common and, depending on the animal, prone to problematic infections. For instance, cats have small teeth and cause deep puncture wounds that easily become infected and require deep exploration to allow antiseptic access to the infected tissue ( Box 2.1 ). By contrast, dogs usually end up tearing soft tissues, and these wounds often require approximation to restore form and function. Meticulous skin closure is sometimes prone to abscess formation, so if the wound is not clean enough, approximation only of the wounds with secondary intention healing is advised, allowing for drainage and washing. Broad-spectrum antibiotics are mandatory.

Human bites are even more liable to cause infection, which is three to five times more common than after animal bites. Human bites are often the result of a fight injury or punch, which may not be admitted by the patient ( Fig. 2.6 ). It is important to recognize these typical lesions of the metacarpophalangeal (MCP) joints ( Fig. 2.6 ) because they must be explored and washed urgently and thoroughly debrided to avoid joint destruction ( Box 2.1 ). Other rarer bites, by snakes, insects, spiders, and so on, may be toxic and may cause severe allergic reactions, depending on the causal organism. They may require specific care and possibly antivenom.

A punch bite injury of the little finger metacarpopharangeal joint at surgical exploration and washout. A piece of the tooth of the “victim” was found within the joint (insert) .

Life-threatening infections.

Some infections can progress very fast and can be devastating and even life-threatening. Immediate recognition is imperative to not only save hands but also lives. Most notorious are necrotizing fasciitis caused by Streptococcus pyogenes and gas gangrene, by Clostridium perfringens . Mortality rates can be as high as 8%, and amputation is needed in 28%. Immediate recognition, surgery, and even life support are mandatory. Amputation may be necessary.

Removal of etiologic factors.

Where possible, removal of any etiologic factor is the first action to be taken, such as removal of a cast or splint, removal of tight dressings, incision and drainage of an infected area, or escharotomies of a circumferential full-thickness burn. Understanding the etiologies and immediate action to remove them are critical. The hand and forearm should be elevated to help venous drainage, and intravenous infusion of mannitol, a diuretic, for several hours to overnight can relieve the symptoms in many patients.

Observation.

For a patient in the early stage of compartment syndrome, observation for a few hours or overnight is the preferred option of management, as the diagnosis of early-stage compartment syndrome is subject to personal judgement, and it is always acceptable to wait for several hours, half a day, or overnight without rushing to surgery. The problem will often resolve. Intravenous infusion of mannitol and hand elevation are very useful in this respect.

Surgical decompression: Middle stage.

For a patient who presents to the clinic with findings of a compartment syndrome in its middle stage of evolution, or who develops worsening symptoms over several hours, or overnight during observation, decompression by surgical fasciotomy is indicated. The patient should proceed to surgery in a timely manner. The purpose of decompression at this stage is to reduce compartment pressure to a non-causal level , reducing the pressure to a level that no longer causes compression to the nerve or vessels, not to return the part to normal. Adequate surgical decompression can be achieved through multiple (three to five) longitudinal skin incisions, each of 4 to 8 cm in length, on the middle and proximal parts of the volar compartment of the forearm and, sometimes, also on the lateral and dorsal compartments of the forearm ( Fig. 2.10 ). The key is the incisions of the deep fascia, which can be cut under the intact skin beyond the skin incisions. In other words, the deep fascia releases are much longer than the skin incisions. This method of adequate fascial release, through short skin incisions, allows easy skin closure later without skin grafting. It avoids the large (and unnecessary) wounds of the classical long skin incision techniques, which cause considerable difficulties of closure and carry a greater risk of infection. For those incisions less than 5 cm long, two to three loosely placed stitches over the skin are sufficient. Jacob’s ladder and “shoelace” techniques can be used for those incisions longer than 5 cm. Of note, in the forearm compartment syndrome, all three compartments should be checked during surgery by palpation of the pressure in each intraoperatively. Some may need several incisions, some may need only one incision, and some may not need incision. In most cases, only one or two compartments need fasciotomy. At this stage, the muscles are usually healthy, although swollen. Further exploration, or dissection, of the muscles is not necessary and, in fact, can be harmful, traumatizing the muscles and leading to increased swelling. The nerves do not need exploration unless the muscles are found to be very tight around them. In the hand, incisions are made on the dorsal aspect, with three to four incisions (each 2–4 cm) in the intermetacarpal spaces. Incisions can be made in the thenar and hypothenar eminence or in the first webspace if there is definitive swelling of these compartments.

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