Hand Infections

Presenter: Dr TN Nakale
Moderator: Dr T. Sefeane
Date: 15 February 2017
Outline

Introduction
Relevant Anatomy
Bacteriology
Types of Infections
Principles of Management
Common Infections
Take home message
 INTRODUCTION
Hand Infections are common esp in immunocompromised
individuals
can spread far and wide from the original site of inoculation
The hand can easily be injured during everyday activity or with minor
trauma, and small wounds are often overlooked
Neglect > involvement rest of hand
can result in severe disabilities, including stiffness, decreased range
of motion, and contracture, and ultimately may require amputation
Adhesions + loss of vital structures
Loss of function
Amputation (Partial > total)
 Relevant Anatomy
Knowledge of the exact location, extent, and mode of spread of
the infection helps determine the appropriate surgical intervention
A detailed knowledge of the hand anatomy is essential for
adequate treatment of hand infections
Various regions and spaces:
(a) the nail complex and pulp space
(b) the synovial spaces
Flexor & Extensor tendon sheaths
Radial bursa
ulnar bursae
(c) the volar and dorsal spaces.
The Nail complex & Pulp space

Nail plate
Perionychium
Eponychium
Hyponychium
Pulp space
 Flexor & Extensor tendon sheaths
Flexor Sheath
Double walled (Visceral &
parietal layer)
From MC neck to DIP
Infection results in Arterial
obstruction + tendon necrosis
Communication with bursae
Extensor Sheath
Synovial sheath for each of 6
compartments
Extends just above & below
dorsal carpal ligament
 Radial & Ulna Bursae

Radial bursa:
Continuation of FPL tendon sheath
Extends to proximal edge of TCL
Ulna Bursa:
Continuation of Flexor tendon sheath LF
Extends proximal to TCL
Communication 33 100% of cases
 Volar Deep Spaces
Thenar Space
Btwn thenar eminence and MF
metacarpal
Boundaries:
Distal: Deep transverse fascia
Proximal: Base of palm
Dorsal: Adductor pollicis fascia
Volar: Palmar fascia
Radial: Adductor pollicis fascia
Ulna: Oblique midpalmar septum
 Volar Deep Spaces
Midpalmar Space
Occurs in midpalm
Boundaries:
Distal: Vertical septa of palmar
aponouroses
Proximal: Base of palm
Dorsal: 2nd/3rd Volar Interosseous
fascia
Volar: Digital flexor sheaths
Radial: Midpalmar septum
Ulna: Hypothenar septum
 Volar Deep Spaces
Hypothenar Space

Potential space btwn hypothenar

septum & muscles
Boundaries:
Dorsal: Fascia deep hypothenar
muscles
Volar: Palmar fascia
Radial: Hypothenar septum
Ulna: Fascia of superficial
hypothenar
 Volar Deep Spaces

Space of Parona

Potential space fascia to PQ and

sheath of FDP
Can communicate with midpalmar
space
Infectiondue to rupture of
radial/Ulna bursae
 Dorsal Deep spaces

Superficial subcutaneous space

Btwn skin & dense aponeuroses

of extensor tendons
No distinct boundaries
Extensive loose connective
tissue
 Dorsal Deep spaces

Deep subaponeurotic space

Potential space btwn

aponeuroses of ext tendons
and periosteum of MC bones
and fascia of dorsal interossei
 Dorsal Deep spaces

Interdigital Web spaces

Btwn fingers
Loose connective tissue
No clear margins
Bacteriology

Staph aureus: Most common 30 80 %

Stretococcus
MRSA: Increasing frequency
Mixed pathogens
Bite wounds
IVI drug users
Immunocompromised
Bacteriology : Local Perspective

Greyling et al, Mennen (2008) Duma, SAOJ

SAOJ (2012) (2016)
Staph Aureus 82% 50% 40%
Strep Pyogenes 9,1% 10% 33%
CNS 5,6%
E. Coli 3%
Klebsiella 1,5% 6%
Bacillus 13%
Enteroccocus 1,5% 6%

MRSA 1,5 %
Type of Infection: Local Perspective
Greyling et al, Mennen (2015)
SAOJ (2012)
Dorsal 42% 10%
Hand/Finger
Flexor 21% 5%
tenosynovitis
Web space 12% 5%
Infection
Deep Palmar 9% 5%
space Infections
Felon 9% 10%
Paronychium 4,6%
Septic Arthritis 1,5% 10%
Human Bites 15%
Septic cuts 20%
Cellulitis 5%
Osteitis 5%
Other 5%
 HIV and Hand Infections
10% in a metropolitan hospital emergency dept
Gonzalez et al, J hand Surg (1998)
35% of Hand infections at Pelonomi Hospital
HIV Positive 5.2 times more likely to have mixed pathogens
More susceptible to Gran Negative organisms
Greyling et al, SAOJ (2012)

41% of Hands Infections due to human bites

No Increased complication rate
Increased hospital stay
Duma & Marais, SAOJ (2016)
Differential diagnosis

Several non-infectious conditions can mimic

hand infections
crystal deposition disease such as gout, pseudogout,
and acute hydroxyapatite deposition
pyogenic granuloma
acute noninfectious flexor tenosynovitis
spider bites
inflammatory arthritides such as rheumatoid arthritis
foreign-body reactions
 Management Principles
Early/superficial infections: nonsurgical Mx(rest,
immobilization, elevation, and antibiotics)
Late: I & D, dbridement, copious irrigation, and
appropriate antibiotics constitute the mainstay of
therapy
Early/adequate decompression of pus to avoid soft
tissue loss
Proper placement of incisions
Appropriate debridement of necrotic tissue
Appropriate antibiotic use as an adjunct to prevent
dissemination of established infection
 Choice of Antibiotics

Cloxacillin is still an effective first line

agent
Clindamycin/Erythromycin are
alternatives
Triple antibiotics for Mixed
pathogens

Greyling et al, SAOJ (2012)

Types of infection &
Management
 Felon
Subcutaneous abscess distal
pulp
Involves multiple septal
Compartments =>
Compartment syndrome
Aetiology
Penetrating wound
Bact contamination of fat pad
If untreated Results in sinus
tract or Osteomyelitis, skin
necrosis
 Felon
Presents with severe pain, Redness and
swelling
Early: Soaks and antibiotics
Late: Surgical drainage
Best Incision: Unilateral Longitudional incision on
non-contact area of digit (ulna IF/MF/RF and radial
thumb/LF)
Other Incisions (Fishmouth/ J or hockeystick/through
& through/volar transverse/midvolar longitudional
are poor choices:
Painful scar
unstable tip
Anaesthetic tip
 Paronychia

Acute or chronic
Involves soft tissue fold and fingernail
Eponychia: Pus beneath nail bed
Inoculation by sliver of nail, manicure
instrument or nail biting
Abscess may extend into pulp space
=> Runaround Infection
 Paronychia

Early management: Soaks and

Antibiotics
Late: Surgical drainage
Remove nail, paronychial fold and
portion of eponychium
Eponychia: Elevate eponychial fold &
excise 1/3 of nail
 Pyogenic flexor tenosynovitis

Closed space infection of flexor tendon

sheath
Increased pressure => Necrosis & Rupture
Decreased motion => Formation of
adhesions
Thumb & LF Infections can spread to radial &
ulna bursae respectively
Horseshoe Abscess
Extensor tenosynovitis: Closed space
infection
 Pyogenic flexor tenosynovitis
Due to Penetrating injury/ Felon
Commonly affects RF/MF/IF
Kanavel 4 cardinal signs
Tenderness over flexor sheath
Fusiform swelling
Pain on passive extension (Most reliable)
Flexed posture
Management
Early: IVI antibiotics, splinting, elevation
Late: surgical drainage: Open vs closed
 Pyogenic flexor tenosynovitis: Open
drainage
Mid-axial and palmar incision to
decompress entire sheath
Leave open to drain and heal by
secondary intention
Useful for advanced cases
Complications
Prolonged rehab
Permanent finger stiffness
 Pyogenic flexor tenosynovitis: Closed
drainage
2 Incisions:
Proximal palm: proximal to A1 pulley
Distal mid-axial: Distal to A4 pulley
Place irrigation catheter in proximal sheath and
drain in distal incision
Close incisions, irrigate 48 72 hrs with NS or Abx
soln
Advantages
Ensures adequate drainage
Heals quickly
Doesnt interfere with rehab
 Deep Palmar : Thenar Space

Most common deep palmar space

infection
Due to
Penetrating Injury
Local spread from adjacent flexor tendon
sheaths
Extension from subcut infection
Spreads dorsally over adductor policis and
1st dorsal interosseous muscle => :
Dumbbell Shaped Abscess
 Deep Palmar : Thenar Space

Presents with
Marked swelling thenar eminence
and 1st webspace
Thumb forced into adduction
Severe pain with
extension/opposition
Deep Palmar : Thenar Space

Management: surgical drainage

Volar or dorsal incisions in 1st web
space or both
Irrigation and drainage
Deep Palmar : Midpalmar Space

Due to
penetrating injury
Infection of tendon sheath
MF or RF rupturing into space
Deep Palmar : Hypothenar Space

Extremely rare
Almost always due to
penetrating injury
 Dorsal Subcutaneous/ Subaponeurotic
space

Due to penetrating injury

(IDU/Neglected human bite)
Subcutaneous infection easily spreads
into subcut of forearm : No barrier to
infection
Subcut and Subaponeurotic
infections often coexist
Dorsal Subcutaneous/ Subaponeurotic
space
Clinical: Dorsal
swelling/Erythema/tenderness
Management:
Linear incisions over 2nd & 4th
Metacarpals
Preserve soft tissue coverage over
tendons
 Webspace Infections

Due to:
Fissure in the skin
Distal palmar callus
extension of an infection in the
subcutaneous area of the proximal
segment of a finger
Begins volar side, extends dorsally
Pus can extend both volarly and
dorsally resulting in hourglass shaped
Collar button or Collar stud abscess
 Webspace Infections
Presents with severe distal
palmar swelling, abducted
finger and pus filled webspaces
Management:
Palmar approach, divide palmar
fascia to expose volar & dorsal
compartments
Do not excise webspace
transversely
Be alert of double abscess
configuration
 Human bite

Commonly undertreated and

misdiagnosed leading to significant
morbidity
Clenched fist: Most severe form of human
bite
Immediate inoculation with saliva
resulting in polymicrobial infection (upto
42 species identified)
Delay in onset of Rx is directly
proportional to poor outcome
Human Bites

Management:
Debridement & Irrigation
Antibiotics: Gram positive, Eikenella (Penicillin &
Cephalosporin)
+- Admission + theater
Animal Bites

Dog bites > Cat bites

Cats more virulent
Principles: Debride and
irrigate
Antibiotics: Ampicillin
 Septic Arthritis

Due to
Penetrating injury
Direct spread from to DIP
felon/paronychia/pyogenic flexor tenosynovitis
Direct inoculation of MCP: Clenched fist injury
Fight bite
Joint swollen, warm and tender, pain on axial
loading
Xrays: thinning of joint/resorption subchondral
bone/ Osteomyelitis (late)
Management:
Longitudinal dorsolateral incision over joint
 Osteomyelitis
Due to
Penetrating injury
Contiguous spread from adjacent
soft tissue infection
Septic Arthritis
Surgery
Haematogenous spread
Mx
Prompt surgical exploration
Remove all infected bone
Amputation if severe
Chronic Infections

Atypical mycobacteum
Tuberculosis
Leprosy
Fungal infection
Postoperative Care

Remove all wound packs in 24 -48 hours

Regular wound cleaning
Gentle active ROM
Splints may enhance joint motion
Early OT
Take Home Message

Hand infections are common conditions that can have

significant morbidity
Immunosuppression seems to play a role in the
bacteriology, number of different organisms cultured
and the antibiotic susceptibility
Cloxacillin remains an adequate first-line treatment for
acute community-acquired bacterial hand infections
Expedient and proper surgical intervention remains the
mainstay of treatment
Early OT to prevent joint stiffness
References

1. Canale S,Beaty J. Campbells Operative Orthopaedics. Edn 12, Vol. 4. Elsevier Mosby,
Canada. 2013 : 3693 - 3712
2. Duma M, Marais L. Early complications of human bites to the hand in HIV positive
patients. SA Orthop J. 2016, 15(4) : 53 57
3. Green DP, Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Greens operative hand
surgery. Edn 7, Vol. 2, Elsevier Churchill Livingstone, USA, 2011, 17-61.
4. Greyling JF, Visser E, ElliotvE. Bacteriology and epidemiology of hand infections. SA
Orthop J. 2012,11:57-61
5. Mennen U, Van Velze C. The handbook: A practical approach to common hand
problems, Edn 3, Van Schaik Publishers, Pretoria. 2008: 169 -183
6. Patel et al. Hand Infections: Anatomy, types and spread of infection, Imaging findings
and treatment options. Radiograhics. 2014 Nov Dec 34(7): 1968 -1986
7. Trker et al. (2014), Hand infections: a retrospective analysis. PeerJ2:e513;
DOI10.7717/peerj.513
8. Website: http://www.slideshare.net/drmoradisyd/hand-infections-16519148