Hand Infections
MBChB IV Surgery II
Dr NT Nakale
27/03/2024
Outline
Introduction
Relevant Anatomy
Bacteriology
Types of Infections
Principles of Management
Take home message
References
INTRODUCTION
Common
can spread far and wide
Minor trauma often overlooked
Neglect > involvement rest of hand
Severe disabilities
Relevant Anatomy
Localizing the infection helps determine surgical intervention
Detailed knowledge of the hand anatomy is essential
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
Paronychium
Pulp space
Flexor 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 tendon sheaths
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 & MF MC)
Midplamar Space
(In the mid palm)
Hyothenar Space
(potential space btwn
hypothenar septum & muscles)
Volar Deep Spaces
Space of Parona
Potential space fascia to PQ and
sheath of FDP
Can communicate with midpalmar
space
Infection due 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
Deep subaponeurotic space
Potential space btwn
aponeuroses of ext tendons
and periosteum of MC bones
Dorsal Deep spaces
Interdigital Web spaces
Btwn fingers
Loose connective tissue
No clear margins
High Risk Patients
Upto 50% of Hand Infections involve
DM
Immunocompromised
IVI drug users
Bites: Human/Animal
Steroids
PVD
Manual labourers
Bacteriology
Staph aureus: Most common 30 – 80 %
Streptococcus
MRSA: Increasing frequency
Mixed pathogens
Bite wounds
IVI drug users
Immunocompromised
Mimickers of Infection
❑crystal deposition disease such as gout, pseudogout,
and acute hydroxyapatite deposition
❑pyogenic granuloma
❑acute non-infectious flexor tenosynovitis
❑spider bites
❑inflammatory arthritides such as rheumatoid arthritis
❑foreign-body reactions
Investigations
Bloods: FBC/U&E/CRP/ESR/HIV/ HBA1C
Xrays
Ultrasound
Management Principles
Early: nonsurgical Mx (rest, immobilization, elevation,
and antibiotics)
Late: I & D, debridement, copious irrigation, and
appropriate antibiotics
Proper placement of incisions
Adequate decompression of pus to avoid soft tissue loss
Appropriate debridement of necrotic tissue
Appropriate antibiotic use as an adjunct to prevent
dissemination of established infection
Early OT
Choice of Antibiotics
Cloxacillin is still an effective first line
agent
Augmentin still a good choice (In
our setting)
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
Complications: sinus tract,
Osteomyelitis, skin necrosis
Felon
Severe pain, Redness and swelling
Surgical drainage
Unilateral Longitudinal incision on non-contact area
of digit (ulna IF/MF/RF and radial thumb/LF)
Other Incisions (Fishmouth/ J or hockey stick/volar
transverse/midvolar longitudinal are poor choices:
Painful scar
unstable tip
Anaesthetic tip
Paronychia
Involves soft tissue fold
Acute : Sliver of nail, manicure
instrument, nail biting
Chronic: Occupation/DM/ART
Eponychia: Pus beneath nail
May extend into pulp space => “Run-
around Infection”
Paronychia
Surgical drainage
Remove ¼ 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: don’t develop the
classic tenosynovitis
Pyogenic flexor tenosynovitis
Due to Penetrating injury/ Felon
Commonly affects RF/MF/IF
Kanavel 4 cardinal signs
Flexed posture
Fusiform swelling
Tenderness over flexor sheath
Pain on passive extension (Most reliable)
Management
Surgical drainage: Open vs closed
Pyogenic flexor tenosynovitis: Open
drainage
Mid-axial and palmar or Brunner 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
Irrigate 48 – 72 hrs with NS or Abx soln
Advantages
Ensures adequate drainage
Heals quickly
Doesn’t 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
Deep Palmar : Thenar Space
Presents with
Marked swelling thenar eminence
and 1st web space
Thumb forced into abduction
Severe pain with
extension/opposition
Deep Palmar : Thenar Space
Management: surgical drainage
Volar or dorsal incisions in 1st web
space or both
Deep Palmar : Midpalmar Space
Due to
penetrating injury
Infection of tendon sheath
MF or RF rupturing into space
Volar Incisions
Deep Palmar : Hypothenar Space
Extremely rare
Almost always due to
penetrating injury
Dorsal Subcutaneous/ Subaponeurotic
space
Due to penetrating injury
(IDU/Neglected human bite)
Can easily spread 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
Web space Infections
Due to:
Fissure in the skin
Distal palmar callus
extension from subcutaneous area
Begins volar side, extends dorsally
“Collar button or Collar stud abscess”
Web space Infections
Severe distal palmar swelling,
abducted finger & pus filled
web spaces
Management:
Palmar approach, divide palmar
fascia to expose volar & dorsal
compartments
Do not excise web space
transversely
Be alert of double abscess
configuration
Human bite
Undertreated & misdiagnosed
Clenched fist: Most severe form of human
bite
Inoculation with saliva: polymicrobial
infection (up to 42 species identified)
S. Aureus/Strep/ Eikenella Corredens
Delay in onset of Rx is directly
proportional to poor outcome
Human Bites
Management:
Debridement & Irrigation
Wide exposure
arthrotomy
Explore structures
Leave open
Antibiotics: Gram positive, Eikenella
(Penicillin & Cephalosporin)
Animal Bites
Dog bites > Cat bites
Cats more virulent
Pasteurella
Multocida/Strep/Staph
Principles: Debride and
irrigate
Antibiotics: Ampicillin
Septic Arthritis
Penetrating injury
Direct spread
Direct inoculation :“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 mycobacterium
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
Take Home Message
Hand infections are common, 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. Campbell’s 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. Green’s 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. Tṻrker et al. (2014), Hand infections: a retrospective analysis. PeerJ2:e513;
DOI10.7717/peerj.513
8. Website: http://www.slideshare.net/drmoradisyd/hand-infections-16519148
