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Plastic Surgery - HAND > Chapter 32 - Hand Infections > Flashcards

Chapter 32 - Hand Infections Flashcards

1
Q

What are the most common bacteria found in hand infections?

A

Staph. aureus (50-80%) and Beta-hemolytic streptococci; >50% are polymicrobial

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2
Q

What is the basic treatment principle when dealing with infections in the hand?

A

DICE: Drainage and Debridement, Immobilization, Chemotherapy (antibiotics), Elevation

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3
Q

What is the most common site for infection (tissue of the hand)?

A

Dorsal subcutaneous tissue, followed by tendon, joint, bone and subfascia

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4
Q

What is the most common mechanism of hand infections?

A

Trauma (penetrating injuries or bites)

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5
Q

How do superficial hand infections tend to be treated?

A

Antibiotics (14-21 days), splinting (depending on severity)

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6
Q

How to deep hand infections tend to be treated?

A

Surgical irrigation and debridement, antibiotics, splinting

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7
Q

What patient risk factors predispose them to hand infections?

A

Immunocompromised states, IV drug use, DM, steroid use, microvascular disease and damaged blood supply (trauma). Infections tend to be virulent.

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8
Q

Whats are the common pathogens found in diabetic patients?

A

Gram negative and polymicrobial, subepidermal abscesses are unique to this population.

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9
Q

How do you treat a herpetic whitlow in an immunocompromised patient

A

Antivirals (will not resolve spontaneously)

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10
Q

What characterizes cellulitis of the hand?

A

Erythema, swelling, tenderness, associated lymphangiitis may indicate a more severe infection

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11
Q

What bacteria is most often seen with cellulitis?

A

Group A Beta-hemolytic streptococcus - S. Aureus may also be seen

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12
Q

What are the oral antibiotics of choice in cellulitis?

A

Nafcillin, dicloxacillin, and cephalexin; erythromycin if pen allergic

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13
Q

What are the most commonly isolated pathogen in human-bite infections?

A

alpha-hemolytic strep and s. aureus

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14
Q

What is the most commonly involved area in human bites

A

MCP joint (“fight bites”)

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15
Q

Where is the most common topography for occurence of hand infections?

A

Flexor tendon zone II

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16
Q

What organism is commonly isolated in one-third of human bite wounds?

A

Eikenella corrodens, 7-29%, must be cultured in 10% CO2, destroys articular cartilage quickly

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17
Q

What is the recommended treatment for human bite injury?

A

Surgical extension and debridement with arthrotomy, culture, antibiotics, leave the wound open

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18
Q

What organism commonly infects animal bites and scratch wounds?

A

Pasturella multilocida

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19
Q

What is necessary for diagnosis and treatment of an animal bite?

A

Xray (to assess bone and foreign objects such as teeth), antibiotics (augmentin or IV unasyn), irrigation

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20
Q

What are the common cultures requested in hand infections?

A

Aerobic, anaerobic, cultures in Lowenstein-Jensen medium for atypical mycobacterium

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21
Q

What are the common stains needed in hand infections?

A

Gram stain, Ziehl-Neelsen (mycobacterium), Tzanck smear (herpes)

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22
Q

When evaluating a hand infection and a fungus is suspected, what preparation is necessary?

A

KOH (potassium hydroxide)

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23
Q

What is the most common infection in the hand of HIV patients?

A

Herpes simplex

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24
Q

When using aminogylcoside (eg gentamicin), for gram negative coverage, what are potential side effects?

A

Nephrotoxicity and ototoxicity

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25
Q

What is the drug of choice for MSSA infections of the hand?

A

cefalexin, augmentin

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26
Q

Whats is the drug of choice for MRSA? IV/Oral

A

Vancomycin, Bactrim, clinda, cipro

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27
Q

What is the current reported incidence of MRSA hand infections?

A

34-73% and rising

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28
Q

What is the most common hand infection?

A

Paronychia - infection beneath the eponychial fold along the paronychial fold and nail plate.

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29
Q

Which is the area around the fingertip most resistant to infection?

A

hyponychium

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30
Q

How do you treat an acute paronychia without abscess?

A

warm water soaks (with or without iodine or chlorhexidine) and oral antibiotics.

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31
Q

How do you treat a paronychia with abscess?

A

I&D, routinely with removal of the nail plate

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32
Q

What is a runaround abscess?

A

a paronychial abscess that tracks around beneath the entire nail fold superficial to the nail plate

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33
Q

What type of patients have chronic paronychial infections?

A

People exposed to constant moisture (dishwashers, swimmers, medical professionals), children who dig in the dirt

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34
Q

What organism is seen in chronic paronychial infections and what is the treatment?

A

Candida albicans; Marsupialization and nail removal; topical corticosteroid-antifungal ointment (3% clioquinol in triamcinilone-nystatin (Mycolog))

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35
Q

In what subset of diabetic patients with hand infections is morbidity particularly high?

A

renal transplant patients

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36
Q

What is a felon?

A

Closed space infection of the digital pulp

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37
Q

What is the most common organism found in felons?

A

MRSA

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38
Q

What is the preferred incision for draining a felon?

A

Mid-volar and high lateral incisions. Longitudinal incisions from distal flexion crease to pulp apex allows for incision of septal compartments while protecting neurovascular bundles

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39
Q

What type of incision is used for draining a felon, is associated with vascular compromise of the digital pad?

A

Fishmouth

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40
Q

What are the consequences of undrained felons?

A

deep-space infections, septic arthritis, osteomyelitis, amputation, acute flexor tenosynovitis, painful/insensate pulp scars

41
Q

How long does viral shedding and ability to infect others persist in people with herpetic whitlow?

A

until lesion epithelialization is complete

42
Q

What is the natural course of a herpetic whitlow

A

self limiting, 3-4 weeks, presents with throbbing pain, tingling, swelling, and erythema (48-72hrs), then erythema and tenderness around clear vesicles which coalesce to form ulcers over 10-14 days. 20% recurrence.

43
Q

Is irrigation and debridement helpful in herpetic whitlow?

A

No. May cause bacterial superinfection.

44
Q

What is pyogenic flexor tenosynovitis of the hand?

A

Bacterial infection of the flexor sheath between the viceral epitenon layer and the outer parietal layer

45
Q

What is the most common bacteria associated with pyogenic flexor tenosynovitis?

A

S. Aureus

46
Q

What are the four cardinal signs of pyogenic flexor tenosynovitis?

A
  1. Flexed resting position
  2. Tenderness over the flexor sheath
  3. Severe pain of passive extension (commonly proximally along the finger tendon sheath)
  4. Fusiform swelling of the finger
    All signs may not be present, especially early
47
Q

What laboratory values are helpful in the diagnosis of flexor tenosynovitis?

A

WBC, ESR, CRP. Elevation of at least one of these values with +clinical exam is 100% specific (not as sensitive)

48
Q

What type of bacterial flexor tenosynovitis usually results from hematogenous spread?

A

Gonococcal infection

49
Q

Which two digital flexor sheaths communicate with bursae in the palm and thus can propagate proximal extension of the tenosynovial infections?

A

Flexor sheath of the thumb (radial bursa) and the small finger (ulnar bursa). The ulnar and radial bursae extend proximally in 50-80% of persons into the carpal tunnel

50
Q

What is a horseshoe abscess?

A

Infection of either small finger or thumb flexor sheath with contiguous spread through communication of the radial and ulnar bursae

51
Q

What has happened if a patient with suppurative flexor tenosynovitis of the small finger suddenly develops acute Carpal tunnel syndrome?

A

Extensive proximal spread of infection into Paronas space

52
Q

What is Paronas space (borders)?

A

Quadrilateral potential space at the wrist bordered by pronator quadratus, pollicus longus and flexor carpi ulnaris

53
Q

Can contiguous spread from the index finger sheath cause infection in the thenar space

A

yes

54
Q

How do you treat early infections of suppurative flexor tenosynovitis (<24hrs)?

A

Elevation, splinting, and IV antibiotics.

55
Q

How do you treat late infections of suppurative flexor tenosynovitis (<24hrs)?

A

Surgical irrigation of the tendon sheath and IV antibiotics

56
Q

If limited incision and catheter irrigation are used, why is it important to make sure the catheter is within the digital sheath?

A

Digital compartment syndrome can occur. The presence of fluid in the interstitial tissue

57
Q

What is the favored exposure for severe tenosynovitis infections with subcutaneous purulence or necrotic tendon?

A

Open exposure of the sheath and irrigation through windows sparing A2 and A4 pulleys, midaxial approach is preferred over Bruner incision to limit postoperative tendon exposure

58
Q

What is the recommended empiric choice and duration of treatment for antibiotics for pyogenic flexor tenosynovitis?

A

Vancomycin and Zosyn for 2-3 weeks

59
Q

What deep spaces of the hand can be involved in infection?

A

Dorsal subaponeurotic, thenar, midpalmar, Parona’s space, interdigital subfascial web spaces

60
Q

Name the possible pertinent infected area for:
Midpalmar space

A

Infection of ring or middle finger flexor tendon sheath

61
Q

Name the possible pertinent infected area for:
Thenar space

A

Infection of the index flexor tendon sheath

62
Q

Name the possible pertinent infected area for:
Dorsal subaponeurotic space

A

Aponeurosis of the extensor tendons (deep)

63
Q

Name the possible pertinent infected area for:
Dorsal subcutaneous space

A

Entire dorsum of the hand

64
Q

What are the most common infectious agents for deep space hand infections?

A

Streptococcus, S. aureus, and coliform organisms

65
Q

What is the name used when the interdigital subfascial webspace is infected?

A

Collar button abscess

66
Q

What is the treatment for infection in the interdigital subfascial webspace (Collar button abscess)

A

I&D, broad spectrum antibiotics

67
Q

In contrast to simple dorsal subcutaneous abscess, a collar button abscess is characterized by:

A

Abducted resting posture of the adjacent digits

68
Q

An infection in the thenar space, first webspace, and dorsoradial aspect of the hand is known as?

A

Dumbbell or pantaloon abscess

69
Q

The boundaries of the thenar space?

A

Volar: index finger flexor tendon
Dorsal: adductor pollicis musculature
Radial: insertion of the adductor pollicis into the proximal phalanx of the thumb and thenar muscle fascia
Ulnar: midpalmar space or oblique septum from the palmar fascia to the volar ridge to the third metacarpal (midpalmar septum)

70
Q

Why is the thumb held in marked abduction in thenar-space infections?

A

This posture reduces pressure and pain

71
Q

What are the mimickers of hand infection?

A

Gout, pseudogout, pyogenic granuloma, pyoderma gangrenosum, neoplasia

72
Q

hat is the most common algae infection seen in fishermen? What antibiotic to use?

A

Prototheca wickerhammi
Tetracycline

73
Q

What are the recommended incisions for drainage of thenar space infections?

A

Combined volar (thenar eminence belly) and dorsal incisions (1st webspace axial to 2nd MC)

74
Q

Why are incisions parallel to the first-web commissure not recommended in thenar space infections?

A

To avoid webspace contracture

75
Q

What is the only infection resulting in loss of palmar concavity?

A

Midpalmar space infection

76
Q

What are the boundaries of the midpalmar space?

A

Volar: flexor tendons and lumbricals
Dorsal: middle and ring finger metacarpals and second and third palmar interosseous muscles
Radial: midpalmar septum
Ulnar: Hypothenar muscles

77
Q

Exposure to what virus causes milker’s node in the hand (or granuloma)?

A

Pox virus

78
Q

What is an interdigital pilonidal cyst?

A

When a foreign piece of hair enters the webspace and becomes secondarily infected

79
Q

What is the usual rate of infections after elective hand surgery?

A

1-7%; 0.47% deep infection rate after CTR

80
Q

What bacteria is associated with coastal or brackish water and what is the treatment?

A

Vibrio vulnificus
Tetracycline, chloramphenicol

81
Q

What bacteria is associated with fresh water and what is the treatment?

A

Mycobacterium marinum
Rifampin, ethambutol TMP-SMX

82
Q

What is sporotrichosis?

A

Chronic granulomatous infection caused by the saprophytic fungus (Sporothrix schenckii). Most common subcutaneous fungal lesion in North America, seen mostly in upper extremities.

83
Q

What is the treatment of choice for sporotrichosis?

A

Oral potassium iodide, or itraconazole if allergic to iodine

84
Q

What organisms are commonly found in septic arthritis of the hand? Cause?

A

S. aureus and streptococcus.
Haemophilus influenzae (young).
Gonococcus (young adult with monoarticular non traumatic septic arthritis).
Penetrating trauma.

85
Q

What is the most common cause of osteomyelitis in the hand?

A

Open fractures

86
Q

Where is the most common location of osteomyelitis in the hand?

A

Distal phalanx

87
Q

What is the most common organism seen in necrotizing fasciitis?

A

Group A strep

88
Q

What is the organism seen in gas gangrene?

A

clostridium perfringins

89
Q

Are there pathognomonic physical findings for deep space infections of the hand?

A

No, but deep infections are frequently associated with abundant tenosynovitis or joint synovia

90
Q

What unique infection can occur in the hands of a patient receiving taxol?

A

Subungual abscess of multiple digits (including toes) with painful onycholysis or nail plate separation

91
Q

How is septic arthritis of the hand transmitted?

A

Commonly by penetrating trauma or spread of infection from contiguous sources

92
Q

What are the physical findings in hand septic arthritis?

A

Fusiform swelling of the joint with erythema and pain upon active range of motion or passive motion

93
Q

How is septic arthritis diagnosed?

A

Joint aspiration with analysis of cultures, cell count (>50,000 cells with >75% PMN leukocytes), crystal count

94
Q

What is the treatment for hand septic arthritis?

A

I&D + antibiotics

95
Q

What is the surgical approach for wrist septic arthritis?

A

Open through longitudinal incisions between 3rd and 4th extensor compartments or via arthroscopy

96
Q

What is the surgical approach for MCP joint septic arthritis?

A

Longitudinal, dorsal incision with at least partial preservation of sagittal bands to prevent extensor tendon subluxation

97
Q

What is the surgical approach for IP joint septic arthritis?

A

midaxial incisions

98
Q

What duration of antibiotics is recommended for septic arthritis of the hand?

A

1-4 weeks of IV antibiotics

Plastic Surgery - HAND (16 decks)

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