Palmar Space Infections



Palmar Space Infections


Hannah A. Dineen

Reid W. Draeger



INTRODUCTION



  • Hand infections, which include cellulitis, paronychia and felons, flexor tenosynovitis, and deep palmar space infections, are frequently encountered by primary care and emergency physicians in addition to orthopedic surgeons. Early diagnosis and treatment is key to optimal outcomes.


  • Epidemiology



    • Occur from direct inoculation from penetrating trauma, or from untreated infections elsewhere in the hand that spread contiguously into the deep spaces of the hand.1


    • Approximately 2% to 15% of hand infections involve the deep spaces of the hand.2,3


  • Pathoanatomy



    • Deep spaces of the hand include the thenar, midpalmar, Parona’s quadrilateral, dorsal subaponeurotic, and interdigital subfascial web space (Figure 47.1 and Table 47.1)1,3,4,5,6


  • Mechanism of injury



    • Infection can occur from inoculation such as penetrating trauma or bites.1


    • Untreated infections in surrounding regions may spread through adjacent spread.


    • More rarely hematogenous spread may occur to any of the palmar spaces.7 Knowledge of anatomy of these regions and their boundaries can help identify and predict spread of deep infection.


    • Untreated flexor tenosynovitis can cause infection within the palmar spaces



      • The radial bursa is contiguous with the flexor pollicis longus (FPL) tendon sheath while the ulnar bursa communicates with the small finger flexor tendon sheath.


      • Approximately 50% to 80% of people have communicating radial and ulnar bursae. This occurs via multiple variations of connections
        between the index, middle, ring, and small finger tendon sheaths, as well as the FPL tendon sheath with the ulnar and radial bursa.7,8 Infections involving the thumb flexor tendon or small finger flexor tendon can thus result in a “horseshoe abscess.”7,8


      • Infection of the index finger flexor tendon sheath can spread to the thenar space, as this sheath is the volar boundary of the thenar space.7


      • Infection involving the thenar space in the interval between the adductor pollicis and first dorsal interossei muscles can cause a “pantaloon” effect.7


      • Contiguous spread of flexor tenosynovitis can continue proximally to involve Parona’s space. The communication that can exist between the radial and ulnar bursa occurs via Parona’s space, and thus can extend to the carpal tunnel.9



        • Controversy exists whether involvement of the carpal tunnel is from communicating spread or through rupture of the bursa.9


      • Parona’s space can also be involved through spread from an infection within the radiocarpal joint and invasion through the volar joint capsule.6



    • Penetrating trauma



      • Hypothenar space infections are very rare and almost always the result of penetrating trauma.10 Contiguous spread of infection does not occur commonly as the boundaries of the hypothenar space keep this compartment isolated.6


    • Infected palmar blisters or skin fissures



      • Collar button abscesses occur in the interdigital subfascial space, typically from spread from an infected palmar blister or skin fissure (see Chapter 46).7 Adherent fascia and palmar skin force the
        abscess to extend dorsally into the web space.7 Additionally, the interdigital web space is contiguous with the dorsal subcutaneous tissue between fingers.3


  • Microbiology



    • Over 90% of infections are bacterial in origin.11


    • Staphylococcus aureus and Streptococcus species are the most commonly implicated bacteria, with Staphylococcus the principal organism in 50% to 80% of infections.7,12



      • S. aureus tends to cause a suppurative infection that peaks in 3 to 6 days.12


      • Staphylococcus epidermidis infections tend to be more superficial.12


      • Methicillin-resistant S. aureus (MRSA) infections are becoming increasingly frequent, with an incidence of 34% to 73% in all hand infections.5,13



        • Risk factors for MRSA infections include patients with diabetes or an immunocompromised state, as well as a history of prior antibiotic use. Additionally, risk factors include those patients living in close spaces such as contact sports, military recruits, day cares, prisoners, or homeless patients.


        • Nosocomial MRSA acquisition can occur from prolonged hospital stays, in particular in an intensive care unit.1


      • Depending on the mechanism of injury, different bacteria may be present (Table 47.2).


      • Trauma is the most common etiology of hand infections followed by a laceration or puncture wound.14



        • Industrial injuries or those within the home typically are a single microbial infection with a Gram-positive organism.7


        • Bite wounds, farm injuries, and infections in IV drug users as well as diabetics are often polymicrobial and involve Gram-negative and anaerobic species in addition to Gram-positive organisms.1



          • ▲ 42 bacterial strains have been isolated in human bite wounds.7


          • ▲ Although alpha-hemolytic Streptococci is the most frequently isolated pathogen, Eikenella corrodens is frequent and isolated about one-third of the time.7,15


          • Pasteurella multocida is found in infections involving dog or cat bites, as this facultative anaerobe is present in two-third of domestic cat and half of domestic dog oral flora.7,12






FIGURE 47.1 Anatomy of deep palmar spaces. Cross-section of hand demonstrates thenar, midpalmar, and hypothenar spaces. From Abrams RA, Botte MJ. Hand infections : treatment recommendations for specific types. J Am Acad Orthop Surg. 1996;4(4):219-230.








TABLE 47.1 Anatomy of Deep Palmar Spaces


























Deep Hand Space


Borders


Thenar space


Dorsal: adductor pollicis


Volar: index flexor tendon


Radial: adductor pollicis insertion at proximal phalanx of thumb


Ulnar boundary: midpalmar (oblique) septum, which separates this from midpalmar space


Midpalmar or deep palmar space


Dorsal: long and ring finger metacarpals, 2nd and 3rd interossei


Volar: long, ring, and small finger flexor tendons and lumbricals


Radial: midpalmar/oblique septum


Ulnar: hypothenar muscles and hypothenar septum


Hypothenar space


Dorsal: periosteum of 5th metacarpal and fascia of deep hypothenar muscles


Volar: palmar fascia and fascia overlying superficial hypothenar muscles


Radial: hypothenar septum


Dorsal subaponeurotic space


Dorsal: extensor tendons


Volar: periosteum of metacarpals and dorsal fascia of interossei


Interdigital subfascial web space


Dorsal: dorsal hand fascia and skin


Volar: palmar fascia


Radial and ulnar: digital extensor mechanism, metacarpophalangeal (MCP) joint capsules, ligamentous structures. This is the palmar space between digits and is continuous with the dorsal subcutaneous space between the fingers


Parona’s quadrilateral space


Dorsal: digital flexor tendons


Volar: pronator quadratus


Radial: flexor pollicis longus


Ulnar: flexor carpi ulnaris


Adapted from Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am. 2014;39(8): 1628-1635. Copyright © 2014 American Society for Surgery of the Hand. With permission.










TABLE 47.2 Antibiotic Recommendations for Specific Clinical Scenario

































Injury/Organism


Antibiotics


Duration of Treatment


Suture line abscess


Cephalexin or sulfamethoxazole/trimethoprim


7-10 d


Abscess


Ampicillin/sulbactam + vancomycin


Cefazolin + vancomycin


Clindamycin if severe penicillin injury


Cat or dog bites


Amoxicillin/clavulanic acid (orally) or ampicillin/sulbactam (intravenously)


If penicillin allergic, ciprofloxacin, ceftriaxone, or doxycycline


7-14 d


Human bites


Cephalosporins


Gentamicin and penicillinase-resistant penicillin


Osteomyelitis


Vancomycin and piperacillin/tazobactam


6-8 wk


Septic arthritis


3-4 wk


Tenosynovitis


2-3 wk


The antibiotics listed in this chart are first-line antibiotics to be used until cultures dictate treatment.


Reprinted from Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am. 2014;39(8): 1628-1635. Copyright © 2014 American Society for Surgery of the Hand. With permission.



EVALUATION



Physical Examination

May 7, 2019 | Posted by in ORTHOPEDIC | Comments Off on Palmar Space Infections
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