HAND INFECTIONS

by nailul muna binti ahmad musadad

الرحمن الله بسمالرحيم

INTRODUCTION Infection of the hands is frequently limited to one of

several well defined compartments:Under the nailfolds (paronychia)The pulp space Subcutaneous tissueTendon tissueOne of deep fascial space/joint

Aetiology : 90 % Staphylococcus aureus

PATHOLOGY Acute inflammation or suppuration in small closed

compartment(tendon sheath or pulp) >increase pressure > can cause local blood supply threatened

Severe case : tissue necrosis

CLINICAL FEATURE Painful and tensely swollen Ill and feverish Throbbing pain Obvious redness and tension in the tissue Tenderness over site of infection Restricted finger movement

TREATMENT

1- ANTIBIOTICS immediately started e.g. Flucloxacillin In severe case : fusidic acid

2- REST AND ELEVATION Mild case : rested in sling Severe case : elevated in roller towel while

the patient is admit for observation.Analgesic give for painkiller

3- SUPPURATION Sign of abscess(sign of infection,marked

tenderness,&toxaemia) > drainage of the pus Tourniquet & general or regional block

anaesthesia Incision made at site of maximal tenderness Pus specimen sent for microbiological

specimen

TREATMENT SPLINTAGE

Removable splintage applied if after draining tendon sheath or fascial space

infections or if conservative treatment prolonged Always with the joints in the position of safe

immobilization Wrist slightly extended , the MCP joints in full

flexion , the interphalangeal joints extended and thumb in abduction

PHYSIOTHERAPY

SPECIFIC TYPES OF INFECTION

1) Cutaneous & sub-cutaneous infections: Paronychia Pulp Space Infection (Felon)

2) Infection of the tendon with its synovial sheath “tenosynovitis”. 3) Fascial spaces infection :

Deep Space Infection i.e. midpalmar space & thenar space

1) PARONYCHIAAnatomy

•Most common infection in the hand•Localized superficial infection or abcess of the lateral nail fold•Typically is due to superficial trauma (e.g. hangnails, nail biting, dishwashing,finger sucking). •The area of infection will be swollen, red and tender

TREATMENT Early sign of infection

antibiotics If the pus present

Lifting the nailfolds from the nail If severe infection with purulent drainage beneath nail, requires

removal of a portion of the nail

A scalpel (knife) is inserted under the skin at the edge of nail to open the pus pocket and drain it to relieve the pressure and treat the infection

The doctor pushes on the swollen area to get the pus out after the incision was

made with the scalpel.

the doctor pushes on the swollen area to get the pus out after the incision was made with the scalpel.

2) PULP SPACE INFECTION (FELON)DEFINITION

subcutaneous tissue of the pulp space of the distal phalanx

ANATOMY The fingertip pulp,

compartmentalized by 15 to 20 fibrous septa running from the periosteum to the skin.

The small compartments contain eccrine sweat glands and fat globules.

The sweat glands provide a potential portal of entry for bacteria.

An abscess in these noncompliant compartments is called a felon.

PULP SPACE INFECTION (FELON) Clinical feature

fingertip swollen, red and tender Mode of infection

Infection typically is due to direct inoculation of bacteria by penetrating trauma(prick/splinter) but may be caused by hematogenous spread and by local spread from an untreated paronychia.

Treatment Antibiotics Incision over site of tenderness

OPERATIVE METHODS

The best is a longitudinal incision over the area of greatest fluctuance.

To avoid penetration of the tendon sheath, the incision should not extend to the distal interphalangeal crease.

3) OTHER SUBCUTANEOUS INFECTION Blister or superficial cut may become infected Clinical feature : redness, swelling and tenderness Treatment :

local collection of pus Drained through small incision over the site of maximal

tenderness. This is to exclude a deeper pocket of pus in an nearby tendon

sheath or in one of deep fascial space.

4) TENDON SHEATH INFECTIONANATOMYo Flexor sheaths are closed spaceso Extend from the mid-palmar crease

to the Distal Interphalangeal joint o Flexor sheath of small finger is

continuous proximally with the Ulnar Bursa, while the sheath of the thumb is continuous with the Radial Bursa

o The synovial sheaths, poorly vascularized and rich in synovial fluid, provide an optimal environment for bacterial growth.

MODE OF INFECTIONo Once inoculated, infection can spread

rapidly within the confines of the sheath.o Infection of the flexor tendon sheath,

known as pyogenic flexor tenosynovitis.

PYOGENIC FLEXOR TENOSYNOVITIS

o Kanavel’s 4 cardinal signs:o Tenderness over & limited to the flexor sheatho Symmetrical enlargement of the digit (“fusiform”)o Severe pain on passive extension of the finger (> proximally)o Flexed posture of the involved digit

o Treatmento Splint and elevateo Administer IV antibioticso If there’s no improvement within 24 hours,consider surgical

drainageo Two incision are needed

o Proximal palmo Distal mid-axial

o the sheath is irrigated with saline or Ringer’s Lactate .o The catheter is left in place for post operative irrigation during

next 2 dayso At the end of operation, the hand is dressing and splinted in the

position of safe immobilization

Most reliable sign: pain with passive extension

5) DEEP FASCIAL SPACE INFECTIONS Infection for a web space or from infected

tendon sheath may spread to either of deep fascial spaces of the palm

Clinical feature : the palm is balloned,so its normal concavity

is loss Extensive tenderness and whole hand is

held still 4 deep spaces clinically significant in

hand infections: Subfascial palmar space Dorsal subaponeurotic space Thenar space Midpalmar space

Treatment For drainage, incision is made directly into the

abscess and sinus forceps inserted Postoperatively, the hand is dressed and splinted

Thenar space infection. Four days after a puncture wound of the thenar crease there is pain, tenderness, swelling and restricted movement. The mid-palmar space was also involved.

Midpalmar Space Infections

Collar stud abscess resulting from stabbing of the thenar crease with an indelible pencil. The deep component of this abscess was in the midpalmar space which became tender and swollen. The middle finger is flexed because of involvement of its tendon sheath.

Web Space “Collar Button” Abscess

A dorsal thenar web space infection

Thenar space infection

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