ORTHOPEDIC

INFECTIONS
 GROUP MEMBERS

● Gabriel Gajadhar ● Rajiv Lutchmedial

● Jessica Jaikaran ● Rei Medford
● Kathryn Ramesar ● Travis Beharry
 OBJECTIVES

● Acute osteomyelitis
● Chronic osteomyelitis
● Septic arthritis
● Hand infections
Osteomyelitis
 Osteomyelitis
● Osteomyelitis
○ Osteo[n] - Bone
○ Myel[o] - Marrow
○ Itis - Inflammation

● Osteomyelitis is a bony inflammation virtually always secondary to

infection

● Classified (Lew and Waldvogel) by

○ Duration/ clinical course → Acute vs Chronic
○ Method of spread → Hematogenous vs Non-Hematogenous

Source: Robbins and Cotran Pathologic Basis of Disease ; UptoDate

Acute
Osteomyelitis
 Definition

● Acute osteomyelitis refers to an inflammatory process evolving over

a “short period” of time (days to weeks)

● Most commonly occurs in children via hematogenous route

● When adults are affected, consider lowered resistance or local

trauma as damaged muscle is an ideal substrate for bacteria,
i.e the exogenous route

Source: Harrison’s Principles of Internal Medicine 20th Ed. ; UptoDate

 Aetiology
● Normal bone is highly resistant to infection

● Osteomyelitis develops when there is a large inoculation of organisms,

presence of bone damage, and/or presence of hardware or other foreign
material.

● Organisms may reach the bone by:

1. hematogenous spread
2. extension from a contiguous site
3. direct implantation.

Source: Robbins and Cotran Pathologic Basis of Disease 9th Ed ;

UptoDate https://www-uptodate-com.ezproxy.sastudents.uwi.tt/contents/pathogenesis-of-osteomyelitis
 Pathophysiology

● May be vertebral or non-vertebral

● Non-vertebral osteomyelitis seen in the metaphysis of long bones

○ Lower Femoral Metaphysis
○ Upper Femoral Metaphysis
○ Upper Tibial Metaphysis
○ Upper Humeral Metaphysis
○ Hips
 Pathophysiology
● The classical changes :

● Inflammation
■ Increased intraosseous pressure - pain and decreased blood flow

● Suppuration
■ Pus in the medulla [Day 2]
■ Tracks along Volkmann canals → Subperiosteal abscess
formation

● Necrosis
■ Compromised blood flow leads to necrosis [Week 1]
 Pathophysiology (cont’d)

● New bone formation

○ Forms from deep periosteum, enclosing infected tissue

● Resolution OR Intractable chronicity

○ If infection controlled, process is halted, bone may reheal
thicker
○ If uncontrolled, infection worsens and process continue
Classification - Cierny and Mader
 Aetiological Agents
● Hematogenous is typically monomicrobial | Direct Inoculation/Contiguous Spread may
be poly or monomicrobial

● Most commonly caused by STAPHYLOCOCCUS AUREUS

○ responsible for 80% to 90% of the cases of culture-positive pyogenic

osteomyelitis

● Escherichia coli, Pseudomonas, and Klebsiella spp.

○ more frequently isolated from individuals with genitourinary tract infections or
who are intravenous drug abusers

Source: Robbins and Cotran Pathologic Basis of Disease 9th Ed

 Aetiological Agents

● Salmonella
○ individuals with sickle cell disease

● Candida Spp
○ Immunocompromised individuals

● Other common organisms

○ Haemophilus influenzae
○ Group B Streptococci

Source: Robbins and Cotran Pathologic Basis of Disease 9th Ed

 Risk Factors

● Recent Trauma/ Surgery

● Open Fractures
● Immunocompromised Patient
● Diabetes Mellitus
● IV Drug Use
● Poor Vascular Supply
● Peripheral Neuropathy
 Presentation
CLINICAL DIAGNOSIS

● May present gradually with onset over a few days but usually manifests within two weeks.

● Local symptoms at the site of infection such as

○ erythema,
○ swelling,
○ warmth
○ Decreased range of motion at the affected joint

● There may be a dull pain with or without motion and sometimes constitutional symptoms
such as:
○ Fever
○ Chills
○ Lethargy
○ Irritability

Source: Osteomyelitis Statpearls https://www.ncbi.nlm.nih.gov/books/NBK532250/

Osteomyelitis Medscape Practice Essentials https://emedicine.medscape.com/article/1348767
 Investigations
● Laboratory investigations can assist in the diagnosis if uncertain, but are generally
non-specific for the diagnosis of osteomyelitis
○ A complete blood count can show leukocytosis and anaemia (WCC rarely >15)
○ Erythrocyte Sedimentation Rate and C-Reactive Protein are usually increased

● Alkaline Phosphatase, Calcium and Phosphate are within NORMAL LIMITS in

osteomyelitis

● Blood cultures are positive in only 50% of osteomyelitis cases

○ Sinus tract cultures do not predict the presence of gram -ve organisms but are
helpful to confirm S. Aureus infection

● Bone biopsy can be used to establish a histopathological diagnosis

○ Is highly invasive

Source: Osteomyelitis Statpearls https://www.ncbi.nlm.nih.gov/books/NBK532250/

Osteomyelitis Medscape Practice Essentials https://emedicine.medscape.com/article/1348767
 Radiology

● Most useful scans are Plain Radiographs, MRI Scan and Tc-99 bone
scintigraphy
○ Plain radiographs - can have delay of ~14 days to detect changes

○ MRI has highest sensitivity and specificity but is impractical

○ 3 phase Tc-99 bone scan reveals increased metabolic activity in

osteomyelitis
■ Indistinguishable from post-surgical or cancer

Source: Osteomyelitis Statpearls https://www.ncbi.nlm.nih.gov/books/NBK532250/

Osteomyelitis Medscape Practice Essentials https://emedicine.medscape.com/article/1348767
Image showing progressive X rays in Acute Osteomyelitis Image showing Tc-99 uptake in
Acute Osteomyelitis
 Treatment
● General treatment
○ IV Fluids
○ Adequate Analgesia
○ Continuous Bed rest
○ Splinting of the affected limb

● Effective specific treatment has 2 main aspects

○ Surgical Containment of the infection
○ Prolonged antibiotics

● Prolonged antibiotic therapy is the cornerstone of treatment - guided by culture and

sensitivity where possible
○ Empiric broad spectrum antibiotic therapy can be initiated until sensitivity data
becomes available

Source: Osteomyelitis Statpearls https://www.ncbi.nlm.nih.gov/books/NBK532250/

Osteomyelitis Medscape Practice Essentials https://emedicine.medscape.com/article/1348767
 Treatment

● If antibiotics given in <48 hours → Drainage may not be necessary

● Abscess should however be drained if

1. No improvement within 36 hours of treatment
2. Signs of deep pus - oedema, fluctuation and swelling
3. If pus is aspirated

● Surgical debridement of diseased bone may be required

○ Antibiotics penetrate poorly into infected fluid collections.

Source: Osteomyelitis Statpearls https://www.ncbi.nlm.nih.gov/books/NBK532250/

Osteomyelitis Medscape Practice Essentials https://emedicine.medscape.com/article/1348767
 Treatment and Follow up

● In adults, antibiotic regimen recommended for 4-6 weeks to achieve

acceptable cure rates with a decreased risk of recurrence

● Once signs of infection subside - movements are encouraged. Full weight

bearing is usually possible after 3-4 weeks

● Patients may need to use crutches to help support weight bearing bones

● Outpatient follow up is key to ensure there is no recurrence of infection

Source: Osteomyelitis Statpearls https://www.ncbi.nlm.nih.gov/books/NBK532250/

Osteomyelitis Medscape Practice Essentials https://emedicine.medscape.com/article/1348767
 Complications
● Spread:
○ infection may spread to the joint (septic arthritis) or to other bones (metastatic
osteomyelitis).

● Pathological fracture:
○ occasionally the bone is so weakened that it fractures at the site of infection or
operative perforation.

● Growth disturbance:
○ if the physis is damaged, there may later be shortening or deformity.

● Persistent infection:
○ treatment must be prompt and effective. ‘Too little too late’ may result in chronic
osteomyelitis.

● Squamous cell carcinoma

Source: Osteomyelitis Statpearls https://www.ncbi.nlm.nih.gov/books/NBK532250/

Apley and Solomon’s Concise system of Orthopedics and Trauma 14th Ed.
 Differential Diagnoses
● Charcot arthropathy especially in people with diabetes
● SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and
osteitis)
● Arthritis including rheumatoid arthritis
● Metastatic bone disease
● Fracture, including pathological and stress fractures.
● Gout
● Avascular necrosis of the bone
● Bursitis
● Sickle cell vaso-occlusive pain crises

Source: Osteomyelitis Statpearls https://www.ncbi.nlm.nih.gov/books/NBK532250/

Osteomyelitis Medscape Practice Essentials https://emedicine.medscape.com/article/1348767
Subacute Haematogenous Osteomyelitis
● A mild presentation - either due to patient resistance or a decreased virulence of the
organism

● Most commonly seen in

○ Distal Tibia
○ Proximal Tibia
○ Distal Femur

● Typical patient - a child/adolescent with pain near one of the large joints
○ Lab results typically negative

● Xray typically shows the classic Brodie Abcess | Radioisotope scans will show
increased activity

Source: Apley and Solomon’s Concise system of Orthopedics and Trauma 14th Ed.
Subacute Haematogenous Osteomyelitis

● Treatment can be conservative, Immobilization

and antibiotics (flucloxacillin and fusidic acid)
intravenously for 4 or 5 days and then orally for
another 6 weeks often result in healing.

● If no response to conservative → open curettage

may be indicated; this is always followed by a
further course of antibiotics

Source: Apley and Solomon’s Concise system of Orthopedics and Trauma 14th Ed.
Brodie’s Abscess
Chronic
Osteomyelitis
 Definition

● Chronic osteomyelitis is a severe, persistent infection of

bone and bone marrow over months and years.
● Chronic osteomyelitis may present as a recurrent or
intermittent disease.
● Typically presents six or more weeks after bone infection
and is characterised by the presence of bone destruction
and formation of sequestra.
Cierny Mader Classification
Cierny Mader Classification
 Causative Organisms

● Staphylococcus aureus (most common)

● Methicillin-resistant S. Aureus
● Staphylococcus epidermidis
● Pseudomonas aeruginosa
● Serratia marcescens
● Escherichia Coli
● Proteus
● Fungi and mycobacterium (rare)
 Pathophysiology

1. Source: Inadequate treatment of acute osteomyelitis, Foreign

implant, Open fracture
2. Sustained infection
3. Vascular compromise
4. Sequestrum formation
5. Involucrum
6. Cloaca
 Risk Factors
● A history of trauma
● open fractures
● surgery
● Implants
● diabetes
● peripheral vascular disease
● malnutrition
● hypotension
● chronic steroid use
● malignancy
● alcoholism
● smoking
● systemic or local immunocompromise
● intravenous drug use
 Clinical Manifestations
● Chronic pain
● Bone tenderness
● Swelling
● Erythema
● Impaired wound healing
● Tissue necrosis
● Pus
● Persistent sinus tracts
● Chills
● Low grade fever
● General malaise
 Investigations

LABORATORY
● C-reactive protein (CRP)
● erythrocyte sedimentation rate (ESR)
● white cell count (WCC)
● Bone culture
● Blood culture
 Imaging
X-ray
Advantage
● Early findings- soft tissue swelling, periosteal reaction, loss of definition, loss of bone density and
osteolysis
● Late findings- increased bone resorption, formation of sequestra and new bone formation in the
periosteum or endosteum
Disadvantage
● Low sensitivity and specificity

CT
Advantage
● Useful in the identification of sequestra and intra-osseous fistulae
● Demonstrates periosteal reaction, bone marrow involvement, and soft tissue involvement
● Used for pre-operative planning and to guide biopsies
Disadvantage
● In the presence of implants its quality degrades
 Imaging Cont’d
MRI
Advantage
● For assessing the bone marrow and the surrounding soft tissues
● It can differentiate bone from soft tissue infections
● Used as an adjunct in estimating the margins required for the debridement, or to assess
the response to therapy
Disadvantage
● Decreased quality in the presence of implants, scar tissue and recent operations

fluorodeoxyglucose positron emission tomography (PET)

Advantage
● highest diagnostic accuracy, both for confirming and excluding the diagnosis of chronic
osteomyelitis
Disadvantage
● Limited availability and high cost
 Imaging Cont’d

Ultrasonography (US)
● used at the early stages for detecting purulent collections within the soft tissues

Others:

● bone scintigraphy

● Leukocyte scintigraphy
 Management

ANTIBIOTIC THERAPY
● Initial empiric antibiotic treatment should be commenced as soon as the
culture samples have been obtained
● For common micro-organisms like S. aureus, treat with IV Nafcillin or
Cefazolin in case of methicillin-susceptible S. aureus (MSSA)
● Treatment with IV Vancomycin for MRSA
● Most commonly, at least six weeks of antimicrobial therapy is necessary
 Surgical Treatment
Involves:
● Adequate drainage
● Extensive debridement of necrotic tissue
● Management of dead space
● Adequate soft-tissue coverage
● Restoration of blood supply
● Bone stabilization if necessary

Indications:
● Unresponsive to antibiotic therapy
● Cierny-Mader stage 3 and 4
● Note in Cierny-Mader class C, treatment may be more harmful than the
osteomyelitis itself
 Complications

● Marjolin’s ulcer
● Joint stiffness
● Pathological fracture
● Extension to adjacent structures
● Abscess
● Sinus tracts
● Septic arthritis
● Amputation
MRI showing Marjolin’s ulcer on forearm
Septic
Arthritis
 DEFINITION

Septic arthritis (SA), also called infectious arthritis,

represents an invasion of a joint space by a wide range of
microorganisms, most commonly bacteria. Various viruses,
mycobacteria, and fungi are also causative.
 EPIDEMIOLOGY
● INCIDENCE: between 2 to 6 cases per 100,000

● The incidence peaks between ages 2 and 3 years and has a male

predominance (2:1)

● In the United States in 2012, septic arthritis was responsible for 16,000

emergency department visits

● more common in children than in adults

 AETIOLOGY
CHILDREN
● Kingella kingae is the most common
gram-negative bacterial cause in children
younger than 2 to 3 years.
● Group B Streptococcus, Staphylococcus aureus,
Neisseria gonorrhea, and gram-negative Bacilli
are common among neonates.
● Neisseria gonorrhea is a concern in sexually
active adolescents.
● The hip joint is most affected in children.
ADULTS
● Staphylococcus aureus: most common in both
adults and children
● Streptococcus pneumonia is less common,
● In young sexually active patients, nontraumatic
acute monoarthritis is most frequently caused by
Neisseria gonorrhea.
● Fungal and mycobacterial organisms present
insidiously and may be more difficult to diagnose
● The knee is the most affected joint in adults
followed by the hip.
 RISK FACTORS

● Advance age
● Medical conditions
● Pre-existing joint disease
○ diabetes
● Recent joint surgery or injection
○ rheumatoid arthritis
● Skin or soft tissue infection ○ cirrhosis

● Injection drug use (IDU) ○ HIV

● Indwelling catheters ● Endocarditis or recent bacteraemia

● Immunosuppression
 PATHOPHYSIOLOGY
● Invasion of the synovium and joint space followed by an inflammatory

process.

● Inflammatory cytokines and proteases mediate joint destruction.

● Bacterial toxins and microbial surface components like staphylococcal

adhesins which promote the binding of the bacteria to intra-articular

proteins.
 MECHANISM OF SPREAD

Septic arthritis develops as a result of:

1. hematogenous seeding,

2. direct inoculation of bacteria into the

joint,

3. contiguous spread from an adjacent soft

tissue or bone infection

 CLINICAL PRESENTATION

History Examination
● Look
● presents acutely with a single swollen and
○ Erythema
painful joint (monoarticular arthritis) ○ Swelling
● Joint pain, swelling, warmth, and restricted ● Feel
movement ○ Pain on palpation of the joint
(tenderness)
● Previous history:
○ Warmth
○ joint disease or trauma,
● Move
○ catheterizations ○ Limited active and passive range of
○ intravenous drug abuse motion
○ needle aspiration of the joint or ● Children: fussiness/irritability, reluctance to
move affected joint, decreased appetite
injections of corticosteroids into the
joint
 KOCHER CRITERIA
Variable & Associated
Score: sum of points
Points
1. Non-weight-bearing (Yes +1)
2. History of measured Score 0 = < 0.2 % risk of septic arthritis

temperature > 38.5 degrees Score 1 = 3% risk of septic arthritis

Celsius (Yes +1) Score 2 = 40% risk of septic arthritis
3. Serum ESR > 40 mm/hr (Yes +1)
Score 3 = 93% risk of septic arthritis
4. Serum WBC > 12,000 cells / mm3
Score 4 = 99.6% risk of septic arthritis
(Yes +1)

Helped clinicians differentiate between septic arthritis and transient tenosynovitis in

pediatric patients with inflamed hips.
 INVESTIGATIONS
Laboratory Imaging
● Complete Blood count:Elevated WBC count with a

left shift

● C-reactive protein and Erythrocyte sedimentation

● Plain radiographs
rate both elevated
● Ultrasonography
● Blood cultures: 2 sets of blood cultures taken to

rule out bacteraemia ● MRI

● Arthrocentesis: most useful diagnostic laboratory

test for identifying septic arthritis

DIAGNOSIS
 ARTHROCENTESIS
Normal joint aspirate

1. Clear

2. Colourless/straw-coloured

3. produces a string-like structure

when ejected from a syringe,

indicating normal viscosity.

 ARTHROCENTESIS
Synovial fluid should be sent for:

1. Gram stain,
2. Bacterial culture and sensitivity
3. White blood cell count with differential,
4. Assessment for crystals (monosodium urate and calcium pyrophosphate crystal deposition
crystals) with a polarizing microscope
5. Alterations in the glucose and protein concentrations of the synovial fluid are nonspecific;
these should not be measured routinely.

Remember:

● Performed prior to administration of antibiotics

● Done under sterile conditions
 ARTHROCENTESIS
Findings:

● Appearance: Infected joint fluid is typically yellow-green

● Leukocyte count of 50,000 to 150,000 cells/microL (mostly neutrophils).

● Negative "string" sign: septic synovial fluid has low viscosity compared to normal synovial fluid (high

viscosity)

● Gram stain is positive in some cases.

○ False-positive (precipitated crystal violet and mucin), False-negative results (crystals are present or if

clotting occurs)
 IMAGING
● Plain Radiography

○ widened joint spaces, bulging of the soft tissues.

○ subchondral bony changes and calcium deposits (late finding)

● Ultrasonography

○ identifying and quantifying the joint effusion

○ aiding in needle aspiration of the joint.

● MRI

○ Sensitive for early detection of joint fluid

○ may reveal abnormalities in surrounding soft tissue and bone and delineate the

extent of cartilaginous involvement

MRI: coronal view of the hip showing
Lateral X ray of the knee showing septic
septic arthritis of right hip
effusion
 DIFFERENTIAL DIAGNOSES
1. Infectious aetiologies: Septic bursitis, Gonococcal arthritis, Lyme disease, Tuberculous

arthritis, Viral (chikungunya, dengue fever, Zika virus), Fungal arthritis (sporotrichosis,

coccidioidomycosis, candidiasis)

2. Inflammatory arthritis: Rheumatoid arthritis, systemic Lupus erythematosus, inflammatory

bowel disease-related arthritis

3. Crystal-induced arthropathies: Acute gout, pseudogout.

4. Systemic infection: Bacterial endocarditis, human immunodeficiency virus

5. Tumour Metastasis
TREATMENT
 ANTIMICROBIAL THERAPY
Empiric intravenous antimicrobial therapy should be initiated promptly after joint aspiration
is complete and cultures obtained:

1. antistaphylococcal coverage: (nafcillin, oxacillin, or vancomycin) for all age and risk
categories.
2. Nongonococcal septic arthritis: intravenous vancomycin directed against
gram-positive organisms
3. Immunocompromised, abuses intravenous drugs or the gram stain is negative, then
a third-generation cephalosporin (ceftriaxone, ceftazidime or cefotaxime)
4. Gonococcal arthritis responds well to intravenous ceftriaxone
 JOINT FLUID DRAINAGE
Approaches to joint drainage for management of septic arthritis in adults include needle

aspiration, arthroscopic drainage, or arthrotomy (open surgical drainage).

● Knee, elbow, ankle, or wrist, may be drained via needle aspiration or arthroscopy.

● Hip, shoulder, or difficult-to-access joint (such as the sternoclavicular joint), should be

drained by arthroscopy.

● In any joint, arthroscopy may facilitate more thorough irrigation.

● Drainage through the arthroscope is replacing open surgical drainage. With arthroscopic

drainage, the operator can visualize the interior of the joint and can drain pus, debride, and

lyse adhesions
 SURGICAL DRAINAGE
Surgical drainage is warranted in the following circumstances

1. Adequate drainage cannot be achieved by needle aspiration or arthroscopy

2. Suspicion for penetrating trauma with a residual foreign body

3. Joint effusion persists after seven days of serial aspiration

Severe infections: repeated aspirations or arthroscopic irrigations, and in some cases,

synovectomy
 PRINCIPLES OF SURGICAL MX
1. Approach: can be performed open or arthroscopically (depending on joint)

2. Irrigation: remove all purulent fluid and irrigate joint

3. Debridement: synovectomy can be performed as needed

4. Cultures: obtain joint fluid and tissue for culture

Treatment of choice: arthroscopic drainage with synovectomy → lower rates of infectious

recurrence than needle aspiration and better functional results than open surgery (Hing Liu

2017)
 ASSESSMENT

● Serial synovial fluid analyses should be performed:

○ demonstrate sterilization of the fluid and decreasing total white blood cell count

as patient is treated

● Clinical Assessment of adequacy of drainage:

○ improvement in fever curve, white blood cell count, joint swelling, and pain
 PROSTHETICS

Prosthetic joint infection often requires aggressive debridement and/or removal of the

prosthesis. The new joint is then replaced with cement which is impregnated with

antibiotics.
 COMPLICATIONS
1. Osteomyelitis

2. Chronic pain

3. Osteonecrosis

4. Leg length discrepancies

5. Sepsis

6. Death
Hand
Infections
Paronychia
It is a soft tissue infection around the fingernail

It is the most common hand infection(⅓ of cases)

There are two types which are acute and chronic

Acute Paronychia
Commonly due to minor trauma from nail biting, thumb sucking and manicures

Usually caused by Staphylococcus aureus

Symptoms include redness, swelling, pain and later on pus besides the nail

Treatment:
Non-operative: Warm soaks, oral antibiotics and avoidance of nail biting

Operative: If abscess present then Incision and drainage and oral antibiotics. Partial or total
nail bed removal may be necessary.
 Chronic Paronychia
Commonly caused by occupations with prolonged exposure to water and irritant acid/alkali
chemicals e.g. dishwashers, gardeners, housekeepers, swimmers, bartenders.

Usually caused by Candida albicans

Risk factors include: Diabetes, psoriasis, steroids,retroviral drugs (indinavir and lamivudine)

Findings include low-grade inflammation (less severe than acute paronychia), nail plate
hypertrophy, prominent transverse ridges on nail plate.

Treatment:
Non-operative: Warm soaks, avoidance of finger sucking, topical antifungals

Operative: Marsupialization
 Felon
An abscess in the pulp of the fingertip

Commonly caused by minor puncture wounds into the pad of the digit
e.g splinter and local spread e.g. from paronychia

Most common organism is Staphylococcus aureus

Symptoms include severe throbbing pain, redness and swelling of fingertip

Treatment:
Non-operative (early felon w/ no drainable abscess) - oral antibiotics

Operative (most cases) - I&D(mid lateral/volar approach) and

IV antibiotics
 Pyogenic Flexor Tenosynovitis
Infection of the synovial sheath that surrounds the flexor tendon

Caused by penetrating trauma to the tendon sheath or direct spread from e.g felon

Most common organism is Staphylococcus aureus

It is a SURGICAL EMERGENCY because it can spread via carpal tunnel to the forearm

Clinical features: Look for Kanavel’s sign which are shown in the next slide
Treatment:

Majority of cases require prompt administration of IV antibiotics and incision and drainage
(e.g irrigation of the tendon sheath by inserting a cannula into one end and allowing the
irrigating fluid to pass along the tendon sheath to the other end)
Herpetic Whitlow
Viral infection of the hand caused by herpes simplex virus (HSV-1).

Common among medical and dental personnel, as well as toddlers and preschoolers.

Findings include small painful fluid filled vesicles around fingertips which may form bullae
and systemic symptoms like fever, malaise and lymphadenopathy.

Diagnosis confirmed by culture, antibody titers or Tzank smear.

Treatment:
Usually self limiting
Can use oral acyclovir in severe cases.

NB: DO NOT DEBRIDE THESE LESIONS!

 Fight Bites
Caused by direct clenched-fist trauma (from tooth) after punching another individual in the
mouth or direct bite.

Most common organisms are: Alpha-hemolytic streptococcus (S. viridans), staphylococcus

aureus and Eikenella corrodens.

Findings are progressive development of pain, swelling, erythema, and drainage over wound

Treatment:
I&D, IV antibiotics (must protect against aerobic and anaerobic bacteria), debridement
Web Space Infections/
Collar Button Abscess
 Web Space Infections/ Collar Button
Abscess
● Definition:
○ Penetrating or web space fissure that is associated with dorsal
swelling
○ Also known as a collar button abscess
● Aetiology:
○ Penetrating injury or a fissure in the web space
○ Infection of a palmar callus in manual laborers
○ Spread from an adjacent palmar subcutaneous abscess.
○ Staphylococcus aureus and group A Streptococcus
Web Space Infections/ Collar Button
Abscess
● Presentation:
○ pain and swelling limited to the web space and distal
palm.
○ The fingers are in an abducted position
● Treatment:
○ A web space abscess requires a combined palmar and
dorsal surgical approach
○ Note the incision landmarks (palmar and dorsal) and
that they do not cross the web space
The image above show the combined palmar and
dorsal surgical approach
Source: UpToDate
Deep Space Infections
 Deep Space Infections
● Definition:
○ Abscess formation in deep spaces of the hand, most
commonly thenar or midpalmar space
○ May also involve the hypothenar space
● Aetiology:
○ Penetrating wounds
○ Spread from web space or flexor sheath infections,
adjacent pyogenic flexor tenosynovitis,subcutaneous
abscess, or hematogenous spread from a distant site
Source: UpToDate
 Deep Space Infections
● Presentation:
○ All deep palmar space infections present with palmar swelling
and tenderness over the involved palmar space and generalized
dorsal swelling
○ Thenar abscess - widely abducted thumb and fullness on dorsum
of the first web space, with pain on adduction or opposition of
thumb
○ A midpalmar space abscess - loss of the normal palmar
concavity.
○ Hypothenar space infections - have much less palmar and dorsal
swelling than thenar or midpalmar space infections.
 Deep Space Infections
● Investigations:
○ An ultrasound examination can help in
confirming the presence and location of an
abscess cavity
● Treatment:
○ Incision and drainage and IV antibiotics
Source: UpToDate
 Fungal
Infections
● Cutaneous
● Subcutaneous
● Deep

● Cutaneous Infections

Chronic infections of the nail bed and are usually caused by C. Albicans
It's more common in people who're constantly exposed to water. Chronically wet skin and excessive
soaking disrupts the natural barrier of the cuticle

Treatment- Topical antifungal & nail plate removal-Systemic

ketoconazole or grievousfan (recalcitrant)
 ● Subcutaneous Infections

Usually caused by Sporothrix Schenckii

Follows penetrating injury while handling plants or soil (thorn)

Ulceration at injury site, lesions from along lymphatics with proximal node involvement
possible

Oral itraconazole (3-6 months) and/or Potassium Iodide Solution

 ● Deep Infections

Caused by Coccidiomycosis

Often a deep infection with Flu-like illness or pneumonia: fever, cough, night sweats, anorexia, chest pain, and dyspnea and

Extrapulmonary findings like

● CNS: meningitis

● Skin: erythema nodosum

● Joints: arthralgia

IV Amphotericin B and Surgical debridement

Necrotizing
Fasciitis
● Necrotising Fasciitis is a bacterial soft tissue infection that spreads
along the soft tissue planes rapidly.

● Risk factors: Immune suppression: Diabetes, AIDS, Cancer, Obesity

Bacterial Introduction: IV drug use, insect bites, skin abrasions,
hypodermic injections

● Group A beta hemolytic streptococcus- most common organism

(strep pyogenes)
Clinical Presentation:

Early symptoms: localised abscess or cellulitis with rapid progression, minimal swelling, no trauma or
discoloration

Late symptoms: severe pain, tachycardia, high fever, chills, rigors

Physical examination findings: skin bullae, discoloration, swelling, edema, dermal induration and erythema

Treatment: Emergency radical debridement with broad spectrum antibiotics

Amputation may be necessary

Cellulitis
Definition: Cellulitis is a superficial bacterial skin infection which affects the dermis and subcutaneous
tissue resulting in swelling, erythema and pain.

● Etiology: Beta-haemolytic streptococci (GAS/S. pyogenes), Staphylococcus Aureus, Streptococci Viridans,

Pseudomonas Aeruginosa

● Clinical Presentation : Fever,chills, pain, erythema, swelling, cutaneous lymphatic edema. Erythematous
skin lesions without distinct margins.

● Cellulitis can affect any part of the body; MOST COMMON THE FEET AND LEGS.
● Investigations: Clinical diagnosis

CBC,

inflammatory markers - ESR and CRP

BMP

Imaging- US and CT/MRI

● Management: Empiric antibiotic therapy and supportive care

● Complications: Septicemia, Osteomyelitis, Septic Shock, Endocarditis

Subaponeurotic Space
Infections
 Subaponeurotic Space Infections

● Definition:
○ Infection located beneath the extensor tendons on the
dorsum of the hand and wrist
● Aetiology:
○ Penetrating trauma and local spread from other hand
infections
 Subaponeurotic Space Infections

● Presentation:
○ Dorsal swelling, erythema, tenderness
● Diagnosis:
○ clinical diagnosis
 Subaponeurotic Space Infections

● Treatment:
○ Surgical - incision and drainage
■ Most are drained from one dorsal incision
■ Large abscesses may require two dorsal incisions

● Complications of surgery:
○ desiccation of extensor tendons
Gas Gangrene
 Gas Gangrene
● Definition:
○ Life-threatening muscle infection that develops either
contiguously from an area of trauma or hematogenously from
the gastrointestinal tract with muscle seeding
● Aetiology:
○ Traumatic gas gangrene - Clostridium perfringens;
(located in soil and gut flora)
○ Spontaneous gangrene - Clostridium septicum.
 Gas Gangrene
● Pathophysiology:
○ Occurs in devitalized, contaminated wounds and leads
to myonecrosis
○ Necrosis of muscle and thrombosis of vessels from
exotoxins of bacteria.
● Presentation:
○ Severe pain and tenderness, local swelling to
massive edema, skin discoloration with hemorrhagic
blebs and bullae, non odorous or sweet odor,
"dishwater pus" discharge, crepitus, fever, relative
tachycardia, and altered mental status
 Gas Gangrene
● Investigations:
○ Xray - Gas streaks within soft tissues
○ Haematology - High White Blood Cell (WBC) and LDH
○ Histology-Gram positive bacilli with absence of neutrophils
● Treatment:
○ Non Operative: High dose IV antibiotics. hyperbaric oxygen
○ chamber.
○ Operative: Radical surgical debridement and fasciotomy
● Complications:
○ Renal Failure, Shock
 REFERENCES
● https://www-uptodate-com.ezproxy.sastudents.uwi.tt/contents/overview-of-hand-in
fections?search=Web%20space%20infections&source=search_result&selectedTitle
=1~150&usage_type=default&display_rank=1#H27991298
● https://www-uptodate-com.ezproxy.sastudents.uwi.tt/contents/clostridial-myonecr
osis?search=Gas%20gangrene&source=search_result&selectedTitle=1~31&usage_t
ype=default&display_rank=1
● https://www.orthobullets.com/trauma/1067/gas-gangrene
● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753838/#:~:text=Collar%20button
%20abscesses%20occur%20from,infection%20from%20adjacent%20anatomical%20
structures.&text=Staphylococcus%20aureus%20and%20group%20A,to%2080%25%2
0of%20positive%20cultures.
● https://www.orthobullets.com/hand/6106/deep-space-and-collar-button-infections
●
 REFERENCES
● https://www.ncbi.nlm.nih.gov/books/NBK538176/
● https://www-uptodate-com.ezproxy.sastudents.uwi.tt/contents/septic-arthritis-in-ad
ults?search=septic%20arthritis&source=search_result&selectedTitle=1~150&usage
_type=default&display_rank=1#H2766713848
● https://emedicine.medscape.com/article/236299-workup
● https://www.orthobullets.com/trauma/1058/septic-arthritis--adult
● https://pubmed.ncbi.nlm.nih.gov/28580269/#:~:text=In%20adults%2C%20arthrosco
pic%20drainage%20with,functional%20results%20than%20open%20surgery .
● https://radiopaedia.org/articles/septic-arthritis#:~:text=Septic%20arthritis%20is%20
a%20destructive,and%20decreased%20range%20of%20motion.
 REFERENCES

● https://emedicine.medscape.com/article/1348767-overview#a7
● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367612/
Thank You