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HAND INFECTIONS

HAND INFECTIONS. Edward Drew Junior Clinical Fellow Burns and Plastic Surgery. General Advice. Potential to cause severe problems Therefore early aggressive treatment is key Bacterial resistance is becoming more common Multidisciplinary approach. Paronychia.

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HAND INFECTIONS

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  1. HAND INFECTIONS Edward Drew Junior Clinical Fellow Burns and Plastic Surgery

  2. General Advice • Potential to cause severe problems • Therefore early aggressive treatment is key • Bacterial resistance is becoming more common • Multidisciplinary approach

  3. Paronychia • Infection of the perionychium or epidermis border of the nail • Acute vs. Chronic • Redness, Swelling, Pain at the base of the nail and later …..pus • Bacterial vs. Viral

  4. Paronychia 2 • Causes: • Acute • Localised Trauma • Dishwashing • Manicure • Ingrown Nail • Thumbsucking in Children

  5. Paronychia 3 • Organisms • S.Aureus and Strep. Pyogenes • Rarely Pseudomonas

  6. Paronychia 4 • Management • Surgical if no spontaneous drainage • Severe infections; anti staphlyococcal penicillin or first generation cephalosporin • Augmentin if suspicion of anaerobes or E.Coli • Viral: Topical antifungal and steroid • Consider Tetanus booster

  7. Felon • More serious • More Painful • Cellulitis and Abscess forms • Between closed space of fatty tissue and the pulp • Needs surgical drainage and Abx • Otherwise local destruction can occur • Usually from a penetrating injury

  8. Felon 2 • Finger tip is divided into compartments by 15-20 fibrous septa that run between periosteum and skin • Abscess formation in these compartments causes pain (non-compliant) • Can cause tissue necrosis • Risk of osteomyelitis • Sinus formation (pressure) • Will not extend proximal to the DIPJ

  9. Felon 3 • Causes • Innoculation of bacteria • Usually penetrating trauma is the culprit • Thumb and Index finger most common • Splinters, Glass, Abrasions • Can be a progression from a paronychia (untreated) • Blood Tests (BM)

  10. Felon 4 • Management • Conservative if caught in cellulitic stage • Elevation, Warm water soaks, Abx • Always X-ray to exclude osteomyelitis/FB • I and D Fluctuancy: watch for numbness, neuroma after volar longitudinal incision and high lateral incision, also unstable finger pad • Aim to avoid flexor tendon sheath • Usually S.Aureus but culture and manage as with paronychia

  11. Herpetic Whitlow • Viral • HPV • Higher in at risk groups • Small swollen blisters • Conservative treatment usually self limiting • Minimal after effects

  12. Herpetic Whitlow 2 • Auto-innoculation into broken skin of HS1/2 • Can be complications from primary oral or genital herpes • Can affect health care workers e.g. dentists

  13. Herpetic Whitlow 3 • Pain out of proportion to clinical findings • Abrupt onset of erythema and pain • Localised tenderness • May have systemic fever/lymphadenopathy • Small clear vessicles are present • Tzanck Test/Viral Culture or DNA amplification

  14. Herpetic Whitlow 4 • Management • Usually self limiting • Lessen with Acyclovir/Famcyclovir/Valacyclovir • Avoid contact with lesion (shedding) • 30-50% recurrence (warn patients) • First infection is usually the most severe

  15. Septic Arthritis/ Osteomyelitis • In or Near a Joint • Very Destructive (Cartilage) • Surgical Drainage and antibiotics required • Osteomyelitis can occur • Can require weeks of antibiotics

  16. Deep Space Infections • E.g. Thenar eminence, palmar space, web between the fingers • Collar button or web space infections • Potential to spread to wrist and forearm • Surgical drainage required

  17. Tendon Sheath Infections • Small Laceration or puncture over finger • Palmar Side • Stiffness and Risk to Tendon • Presentation of ‘Quad’ of symptoms • Surgical Irrigation of the sheath with Abx • Diabetes can complicate and even result in digit loss

  18. Tendon Sheath Infections 2 • Poorly vascularised and rich in synovial fluid • Infection spreads rapidly • Clinically presents with…

  19. Tendon Sheath Infections 3 • Uniform symmetric digit swelling • Held in flexion at rest • Excessive tenderness along the length of the tendon • Pain with passive extension*

  20. Tendon Sheath Infections 4 • Management • Treat early to avoid tendon necrosis/adhesion and spread to deep spaces • Remove rings • May initially respond to Abx and Elevation • Guided Abx Therapy (usually Staph/Strep) • Tetanus Status • Surgical intervention early if warranted

  21. Bite Wounds • Associated with several bacteria • Not just stretococcus and staphylococcus (Driven in) • Eikenella Corodons with mouth • Pasteurella Multicocida (Dog and Cat) • Rabies Infections – Severe +/- Fatal • Surgical treatment – two stage +

  22. Bite Wounds 2 • Fight Bite – teeth can penetrate extensor sheath and joint capsule (75% in jury to bone/tendon/joint/cartilage) • X-ray for foreign bodies/osteomyelitis/gas • Thorough examination; do not underestimate • Guided antibiotic therapy • Human bites more virulent than animal • Splint hand. Delayed Closure.

  23. Atypical Mycobacterial Infections • Gradual Onset in flexor sheath • Swelling and stiffness but not much pain or redness • Treated with special antibiotics for months • Surgical removal of the infected tendon linings may be required • Residual stiffness is common • Impaired immune systems are more susceptible • Mycobacterium marinum (stagnant water/Fish spines) • Can affect soft tissues of hand

  24. Differentials • Gout/Pseudogout • Pyogenic Granuloma • Calcium Deposition • RA • Acute non-specific flexor tenosynovitis • Brown recluse spider bites

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