1. HAND INFECTIONS Col. T.L.B. le Roux Maj. A.J. Julyan Department of Orthopeadic Surgery 1 Military Hospital 2012 From : The Hand Book (Chapter 5)

2. INTRODUCTION • One of the most serious hand injuries • Most important cause of hand swelling • Neglect > involvement rest of hand • Adhesions + loss of vital structures • Loss of function • Amputation (Partial > total)

3. MANAGEMENT • Correct and early diagnosis • Correct, early and aggressive surgical and medical management • Early mobilization and rehabilitation

4. PATHOPHYSIOLOGY • Organisms via various routes • Direct penetration, haematogenous, anatomical tissue planes • Local tissue reaction and oedema • Tissue tension > impaired circulation • Microvascular thrombosis and ischemia • Abscess formation

5. AIM OF TREATMENT • Preserve good circulation • Arrest microbial proliferation

6. PRINCIPLES OF TREATMENT • Early decongestion by abscess drainage • Appropriate dressing to allow draining • Splinting of the hand in the correct physiological (functional) position • Elevation to reduce swelling • Appropriate antibiotics when applicable • Hand baths • Early mobilization and rehabilitation

7. BACTERIOLOGY • Most common : Staphylococcus aureus • Other 50% : Streptococci, Gram negative organisms, fungi, TB

8. SYMPTOMS + SIGNS • Hallmarks of inflammation: • Throbbing pain • Raised local skin temperature • Redness • Tenderness • Swelling • Severity and expressiveness: • Type of injury • Type of organism

9. SPECIAL INVESTIGATIONS • Sound clinical judgement – most important • X – rays : osteitis or septic arthritis • Bacteriological studies • Mixed, chronic infections • Extraordinary ( TB, Fungal ) • Histology • Serology : Gonococcus, Syphilis, Brucella • Biochem : Gout

10. DIFFERENTIAL DIAGNOSIS • Aseptic inflammatory conditions • Gout, OA, De Quervain’s, non-infectious tenosynovitis • Allergic conditions • Peripheral vascular disease, peripheral nerve disease, diabetes mellitus • Poor blood supply, slower healing, resistant to antibiotics • Insect bites

11. TREATMENT - Anaesthesia • Necessary for thorough debridement and wound toilet • Children : General anaesthetic • Adults : General or regional ( brachial plexus, axillary, subacromial )

12. Treatment – Bloodless field • Mandatory • Elevate the hand for 30 – 60 seconds • Dangerous to use Eschmarch or other kind of bandage to accomplish a bloodless field • The septic process could be squeezed proximally

13. Treatment - Incision

14. Treatment - Dressings • Plugs should never be used • One layer of paraffin gauze – packed with loose gauze swabs • Dressings removed within 24 hours • Followed by hand baths • Avoid Eusol and Saline > tissue damage • Rather Plasmalyte B, Ringers

15. Treatment - Dressings

16. Treatment - Debridement • Drained abscess – cleaned out – tip of finger • Soft tissue adhering – must be removed • Prevents chronic discharge

17. Treatment - Splinting • Splint the postoperated hand in a functional position • Reduces the swelling, relaxation of lymphatics and veins • Alleviates pain • Functional (Physiological) position • Wrist in 30 degrees of dorsiflexion • MP joints in 90 degrees of flexion • Interphalangeal joints in full extension • First webspace in full abduction and extension of the first metacarpal (open)

18. Treatment – Hand baths • Very important for mechanical cleaning • Large bowl with lukewarm water and soap • Patient cleans with his other hand • Closed with dressing afterwards • Repeated 3-4 times daily • Use Hibidil or Savlon • Start immediate hand therapy after dressings

19. Treatment - Swelling • Early mobilization – reducing swelling – regaining full function • Not later than 12 – 24 hours after surgery • Enemy of the hand is oedema • It inevitably leads to fibrosis and stiffness • Elevate above the level of the hart

20. Treatment – Antibiotics • In general not necessary – source removed • Take swabs with initial debridement • If any doubt exists – appropriate A/B • Also indicated in early stages of infection • When pus collection is evident the treatment is surgical drainage not A/B

21. Treatment – Analgesics • These are painful conditions! • Effective pain relief – enhances early mobilization • Be aggressive and break the pain cycle • Combination of Opiate, NSAID, Sedative • Most also available IVI

22. Complications • Chronicity • Diabetes, Gout, peripheral vascular disease • Persistent drainage • Incomplete drainage, foreign bodies, osteitis and soft tissue sequestrum • Leads to persistent drainage • Initial debridement shouldn’t leave behind any devitalized, dead or foreign tissue

23. Complications

24. Complications • Joint stiffness • Delayed onset of mobilization • Incorrect dressings, pain, oedema • Spreading infection • Delayed treatment • Gas gangrene • Farm or outdoor related injury • Aggressive debridement, rinsing and A/B

25. SPECIAL INFECTIONS • Streptococcal infections • Human bites • Osteitis • Septic arthritis • Lymphangitis • Necrotizing fasciitis • Pyogenic Granuloma

26. SPECIAL INFECTIONS • Postoperative wound infection • Burns • Paronychia and eponychia • Felon or pulp space infection • Palmar space infections • Septic tenosynovitis • Leprosy, TB, Mycobacterium Marinum • Dorsum hand and others

27. Streptococcal infections • Rapidly spreading cellulitis without abscess formation • Epithelium is elevated by a collection of serous fluid – blister • Treatment : • Remove elevated epithelium • Paraffin gauze • Appropriate A/B

28. Streptococcal infections

29. Human Bites • Most septic and most serious bite • Mixed flora – extremely pathogenic to normal tissue • Tips of fingers, knuckles • “ Fight bite” – • Attacker with finger in full flexion • Presents as patient fingers in extension • Superficial puncture wound • Much deeper into MP joints – “closing off “

30. Human bites • Treatment aggressive – debridement wide and with fingers in flexion and extension • A/B : Triple therapy – Penicillin, Aminoglycoside, Metronidazole • Can still cause osteitis • Sometimes partial amputation only way to stop spread of infection

31. DOGBITE

32. DOGBITE

33. Septic Arthritis • Should be distinguished from gouty arthritis • Arthrotomy and debridement • Synovectomy and irrigation • Appropriate A/B • Joint mobilization

34. Lymphangitis • Red streak on the dorsum of hand or volar aspect of forearm • Streptococcal origin • Elevation • Splintage • IVI Penicillin

35. Necrotizing Fasciitis • Causitive organism : Clostridia family – mostly Perfringens • Sometimes Streptococci • Overwhelming, fast spreading, with systemic toxic symptoms • Radical surgical debridement and re-debridement • IVI A/B : Start on high doses Penicillin

36. Pyogenic Granuloma • “ Proud flesh “ • Overgrowth of granulation tissue • Chemical cauterization : • Silver Nitrate • Iodine • Surgical removal and skin grafting • Send for histology

37. Pyogenic Granuloma

38. Postoperative Wound Infection • Prevention : • Aseptic techniques • Gentle tissue handling • Preservation of blood flow • Prevention of oedema • Treatment : • Removal of sutures • Hand baths • A/B

39. Paronychia • Early stages – elevation and A/B • Collection of pus – drained • Remove lateral aspect of nail – can form sequestrum • Osteitis

40. Eponychium • Infection of the nail fold in the Lunula region • Elevated part of nail to be removed by two lateral incisions • Chronic – Candida or Monilia

41. Pulp space infection (Felon) • Detrimental to blood supply • Osteomyelitis

42. Felon

43. Palmar space infections

44. Palmar Space Infections • Webspace, thenar or midpalmar • Cause : • Septic callus, septic blister, tenosynovitis, direct inoculation • Treatment : • Approach webspaces directly • Blunt dissection • Evacuate the abscess

45. Septic Tenosynovitis • Serious infection • Massive oedema of finger • May spread via synovial sheaths • Kanavel’s four cardinal signs • Early incision and irrigation • Hand is elevated • Mobilization is delayed for 3-4 days

46. Kanavel’s four signs • Slight flexion of finger • Swelling • Pinpoint tenderness over sheath • Pain on passive extension

47. Septic Tenosynovitis

48. Septic Tenosynovitis

49. Leprosy • Staged and rare infection • Inflammatory stage – leads to an absolutely stiff hand • High doses Cortisone • Loss of sensation – burns and injuries • Osteomyelitis can follow • Drugs : Dapsone, Rifampicin, Clofazimine

50. Tuberculosis • Not uncommon in the wrist joint • Diagnosis difficult • Mostly confirmed with synovial biopsy • Treatment : • Synovectomy • Splintage • Rehabilitation • Drug regime