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 • 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
Paronychia 2 • Causes: • Acute • Localised Trauma • Dishwashing • Manicure • Ingrown Nail • Thumbsucking in Children
Paronychia 3 • Organisms • S.Aureus and Strep. Pyogenes • Rarely Pseudomonas
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
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
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
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)
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
Herpetic Whitlow • Viral • HPV • Higher in at risk groups • Small swollen blisters • Conservative treatment usually self limiting • Minimal after effects
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
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
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
Septic Arthritis/ Osteomyelitis • In or Near a Joint • Very Destructive (Cartilage) • Surgical Drainage and antibiotics required • Osteomyelitis can occur • Can require weeks of antibiotics
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
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
Tendon Sheath Infections 2 • Poorly vascularised and rich in synovial fluid • Infection spreads rapidly • Clinically presents with…
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*
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
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 +
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.
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
Differentials • Gout/Pseudogout • Pyogenic Granuloma • Calcium Deposition • RA • Acute non-specific flexor tenosynovitis • Brown recluse spider bites
