HAND INFECTIONS

Ahmad Fauzi, MD

Orthopaedic and Traumatology Department

Introduction
 Hand infections can be associated with considerable morbidity
 Expeditious treatment is needed to minimize permanent
dysfunction, loss of work, and medical cost
 Pathogens include a variety of bacteria, viruses, yeasts, fungi, and
mycoplasmata
 Management frequently involves rest, elevation, incision and
drainage, and appropriate antibiotic therapy
Hand infections can affect the skin, subcutaneous tissues,
fascia, subfascial and synovial spaces, joints, and bone
Microbiology

 Staphylococcus aureus, Streptococcus

and gram-negative species
 Information about nature of the injury
and course of infection is important
 Industrial and home acquired injury  single, gram-positive
organism
 Bite wounds, farm injury, diabetes mellitus  polymicrobial,
gram positive and negative
 Routine aerobic and anaerobic cultures and Gram stain should be
done
 If atypical mycobacteria are suspected, Ziehl-Neelsen staining and
cultures at 28°C to 32°C in Löwenstein-Jensen medium should be
performed
 Antibiotic Therapy
 Antibiotics should be administered empirically after performing
culture and gram stain
 Excessive antibiotic coverage can produce resistant organism, costly
and possibility of unnecessary side effect
 IV drug abuser and diabetic patients require Gram-negative coverage
Specific Types of Infection
 Cellulitis  Human bites
 Subcutaneous Abscess  Animal bites
 Paronychia  Osteomyelitis
 Felon/Herpetic Whitlow  Necrotizing Fasciitis
 Flexor tenosynovitis  Mycobacterial Infections
 Deep space infections  Fungal Infections
 Septic Arthritis
Cellulitis
 A spreading, diffuse inflammation characterized by hyperemia,
leucocytic infiltration and edema
 Group A b-hemolytic Streptococcus is usually the causative organism
 Occasionally, S aureus causes less extensive cellulitis
 Diagnosis is based on clinical findings
 Oral antibiotics for early case, IV antibiotics if no resolution
apparent
 Coverage for Staphylococcus aureus and Streptococcus is
necessary if the causative organism is not known
Streptococcal cellulitis of the left middle finger. The dorsum of the
hand is also swollen
Subcutaneous Abscess
 A subcutaneous abscess usually results from a puncture wound
that inoculates the subcutaneous layer
 The most common organism is S aureus
 Physical examination frequently demonstrates surrounding edema,
cellulitis, and a central area of fluctuation
 Expeditious incision and drainage before instituting antibiotic
therapy can provide the necessary specimen while simultaneously
achieving definitive treatment
 Postoperatively, the wound is left open with a moist bulky dressing
and subsequently managed as previously discussed
 Initial empiric antibiotic treatment should be with a first-
generation cephalosporin
 If the infection originated from a farmyard or similar injury,
penicillin should be added for anaerobic coverage
 If the patient is diabetic or the abscess originated from IV drug
abuse, Gram-negative coverage (e.g., with gentamicin) is included
 Paronychia

Minor injury to the nail folds lead to

cellulitis
Due to the relatively poor blood
supply and poor capacity for
distension of the semi rigid tissue
the infections often leads to abscess
formation which can be eponychial,
paronychial or subonychial
Acute infection beneath the nail Chronic paronychia of the left
fold thumb
 After manicures, artificial
nails, nail biters
 Mostly Staphylococcus aureus
 Fungal infection particularly
Candida albicans for chronic
cases
 Treatment include antibiotics and
adequate drainage
 Chronic paronychia require
marsupialization and total nail
removal
 Felon

 Closed-space infections of digital

pulps
 Digital pad is a closed, poorly
compliant compartment containing
latticework of fascial septa extending
from distal phalang to the skin
 Intense throbbing pain and swelling,
usually after penetrating trauma
 Early treatment is mandatory, do not
wait until fluctuation present
 If untreated may lead to
osteomyelitis, tenosynovitis add/or
skin necrosis
Lateral pulp infection Recurrent apical pulp infection in a
patient with Raynaud disease
High lateral incision are preferred with the point of maximum
tenderness as guidelines
Herpetic Whitlow
 Whitlow is synonymous with felon
 Herpetic whitlow is hand infections caused by the herpes virus
 Self limited disease, resolving 7-10 days. Acyclovir is
recommended
 Do not misdiagnose as paronychia or felon as unnecessary incision
and drainage may lead to superinfection
 Characteristic :
 Painful
 Vesicles that coalesce and eventually ulcerate
 Lymphadenitis, fever and malaise
 Flexor Tenosynovitis
 Extend from A1 pulley to Distal
Interphalangeal Joint
 The sheath of the thumb is contiguous with
the radial bursa
 The sheath of the small finger is contiguous
with the ulnar bursa
 The radial bursa communicate with ulnar
bursa in 50-80%
 Usually from penetrating trauma
 Mostly S aureus, but Streptococcus and
gram-negative are frequently involved
Four sign of KANAVEL
1. Flexed resting position
2. Tenderness along the flexor
sheath
3. Fusiform swelling
4. Pain on passive extension
 Delay in treatment may result in
tendon vascular compromise and
necrosis, adhesion and poor gliding
 May spread to contiguous deep
space (radial bursa, ulnar bursa,
horse shoe abscess, Parona space)
 Early case : elevation, splinting, IV
antibiotics
 No improvement in 24 hours,
surgical drainage is necessary
 Limited incision and catheter
irrigation
Flexor Tenosynovitis

If the purulent material is too viscous, open irrigation is necessary

 Deep-Space Infections

 Thenar space
 Midpalmar space
 Parona space
From penetrating trauma or contiguous spread from flexor synovitis
Resting posture in palmarly abducted thumb because the
greatest volume available
 Thenar space infections

 Antibiotics
 Combined dorsal-palmar two
incisions
 Midpalmar space infections

 Direct penetrating trauma or

contiguous spread from flexor
synovitis
 Marked tenderness, lost of normal
concavity of hand instead it appears
flattened
Parona space infections
 Contiguous spread from flexor synovitis
 Acute carpal tunnel syndrome and pain with finger flexor motion
 Wide exposure and thorough drainage
 Avoid incisions directly over flexor tendons and median nerve to
prevent desiccation
Septic Arthritis
 The usual mechanisms of handjoint infections include direct
penetration and extension from contiguous infection or
hematogenous spread
 Staphylococcus aureus and Streptococcus organisms are most prevalent
 Haemophilus influenzae should be considered in the young child,
and Gonococcus infection should be considered in the young adult
with monarticular nontraumatic septic arthritis
 Definitive incision and drainage allows evacuation of the offending
exudate, removal of pannus and necrotic debris, and reduction of
intra-articular pressure
 Incisions should be straight to avoid flap-tip necrosis
 The wrist is drained dorsally, with the entry usually between the
third and fourth dorsal wrist compartments
 Postoperatively, the wound can be left open for delayed primary
closure or can be allowed to heal by secondary intention
 Parenteral antibiotics are continued until local and systemic signs
have resolved
Human bite

Clenched-fist injury with a wound over the metacarpal head and true
bite-induced wound
Human bite

 Infected human-bite wounds that present late (more than 24 hours

after the bite) are usually infected
 Two typical injuries occur : clenchedfist injuries, with a wound
over the metacarpal head, and true bite-induced wounds
 Exploration, irrigation and debridement (may be re-debridement)
without any suture or pins, secondary closure, antibiotics,
hospitalization
Animal bites

 Prevalence dogs > cats > rodent

 Hand is one of the most often site involved
 Staphylococcus, streptococcus, anaerobes
 Do not forget rabies
 Antibiotics and meticulous wound irrigation and debridement
 Animal bites

Septic flexor tenosynovitis of the

right middle finger of a
veterinary surgeon who was
bitten by a cat over the proximal
interphalangeal joint crease
Osteomyelitis

 Open fractures as the most common causes

 Physical findings include pain, erythema, and swelling
 Systemic symptoms are rare unless there is a severe fulminant infection
 In the acute phase, nuclear medicine studies may depict pathologic
changes before they are visualized on x-ray films
 Treatment consist of IV antibiotics, surgical debridement
 Acute osteomyelitis 5 weeks after lateral pulp infection
 X ray rarefaction of the distal phalanx
Necrotizing Fasciitis
 a life- and limb-threatening soft-tissue infection
 The extremities are the most common sites of infection, which is
usually initiated by major or minor trauma
 Most frequent : group A Streptococcus
 17 Other organisms found in polymicrobial infections include a-
and b-hemolytic Streptococcus, Staphylococcus species, and anaerobes
 Characterized by intensely painful, rapidly advancing, poorly
demarcated cellulitis with tensely swollen, shiny skin
 Within a few days, bullae and ecchymoses appear
 The definitive diagnosis is made at surgery when fibrinous
necrotic tissue is found to be accompanied by liquefaction of the
subcutaneous fat and a characteristic, often foulsmelling, thin fluid
referred to as “dishwater pus”
 Antibiotics are started emergently and empirically, including high
doses of penicillin G as coverage for penicillinase-resistant
Staphylococcus
Mycobacterial Infections
 Mycobacterium marinum is the most frequently identified organism
 No pathognomonic physical findings, although deep infections are
frequently associated with abundant tenosynovitis or joint
synovitis
 A subcutaneous lesion should be debrided, and antibiotics should
be administered for 2 to 6 months
 Deep lesions should be treated with tenosynovectomy,
synovectomy, or adequate incision and drainage of the infected
bone or joint, with antibiotic administration for 4 to 24 months
Fungal Infections
 Four categories : cutaneous, subcutaneous, deep, and systemic
 Uncomplicated skin infections are treatable with topical agents,
such as tolnaftate and miconazole
 Onychomychosis typically occurs in hands that remain moist; it
begins as a minor paronychial infection and progresses to whole-
nail involvement characterized by thickening, softening,
discoloration, and cracking
 Nail removal and application of topical agents are less successful
than oral administration of griseofulvin or ketoconazole for
systemic effect
 Subcutaneous and deep fungal infections are often overlooked in
the differential diagnosis of hand infections
 Because sporotrichosis is difficult to diagnose on the basis of
standard stains, definitive diagnosis requires cultures
 The treatment of choice is oral potassium iodide
 Deep fungal infections of the hand can involve tenosynovium,
joints, or bones
 Organisms can be virulent (histoplasmosis, blastomycosis,
coccidioidomycosis) or opportunistic (mucormycosis,
aspergillosis, candidiasis) with the latter affecting the
immunosuppressed patient
 Treatment requires debridement and administration of
amphotericin B
 Coccidioidomycosis arthritis is particularly resistant to treatment
and can be managed only by amputation or arthrodesis
Summary
 The morbidity of hand infections can be decreased with
understanding of the different types of hand infections often
unique to the particular anatomy of the hand
 For optimal results, aggressive treatment must be instituted
expeditiously, followed by appropriate aftercare
 This frequently entails incision and drainage, antibiotic therapy,
wound care, edema control, and mobilization
Thank you