Hand infection Flashcards
Patients who use tobacco should be expected to have slower
healing.
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The location of
wounds can influence decision-making.
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Signs of progressing infection
pain with passive ROM and
ascending lymphangitis,
A critical step in the workup of hand infection is determining
whether a patient needs hospitalization versus outpatient management
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Hospitalization Indications
ascending lymphangitis,
a failed trial of oral antibiotics,
systemic symptoms,
elevated white blood cell (WBC) count,
needing operative intervention,
a high risk of not following-up.
indications
for surgical management
Fluctuance, purulent drainage, and worsening pain
MRSA infections tend to present with more skin
necrosis
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Immunocompromised
patients are more susceptible to fungal, mycobacteria
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Tissue culture will be
more reliable than culture swabs
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Elevation and rest are standard treatment adjuncts for infection
and are important components of pain management.
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position of function
wrist extended 30°, MCP flexed 90°, digits extended
Hand soaks are commonly used in the acute setting and rehabilitation phase,
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report better pain
control and ability to perform ROM exercises when the hand is submerged in warm solution
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, treatment comprises hand soaks, oral antibiotics, and hand elevation. A first-generation cephalosporin of acute paronychia
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I + D is performed by incising the skin longitudinally
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Chronic paronychias present as longstanding induration, pain, erythema along the nail fold, nail plate ridges, elevation of the skin off the
nail plate, and occasional drainage
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The nail plate may be thickened and
discolored in chronic paronychia
F The nail plate may be thickened and
discolored due to concomitant onychomycosis
antifungal coverage for Candida albicans with nystatin or itraconazole is generally required, along with marsupialization (excision of
semilunar patch of eponychial skin and subcutaneous tissue down to
the germinal matrix
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Topical gentian violet is a historic treatment for
chronic paronychia that is gaining popularity again
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Because of the
extensive septae within the pulp, infection remains localized within a
small compartment
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A felon can present without swelling
T throbbing
pain, often without visible external swelling until infection is advanced
scars can become hypersensitive
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Delay in I + D of these abscesses can result in pulp necrosis,
osteomyelitis, or extension of infection into the flexor sheath.
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Untreated infectious tenosynovitis leads to
stiffness, chronic
pain, osteomyelitis, and ascending limb-threatening infection
If caught within 24 to 48 hours with mild or equivocal Kanaval signs, treated with with IV antibiotics, rest, elevation, and inpatient monitoring alone
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Whom should
undergo surgical decompression in the operating room
Anyone presenting with symptoms longer than 48 hours, Kanaval
signs, or worsening symptoms with conservative management
hand therapy can be
started 24 to 48 hours after surgery
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indicators of a poor prognosis.in flexor tenosynovitistes
Subcutaneous purulence and
digit ischemia on presentation
the most common hand infection
Cellulitis
Indication of admission with cellulitis
Ascending lymphangitis, elevated WBC, altered mental status, or lack of response to oral
antibiotics warrant inpatient admission and IV antibiotics
Surgery is
not indicated for cellulitis
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X-rays should be performed if there is suspicion
of a retained foreign body or fracture in case of fight bite fracture
Fight bites require exploration of the wound to rule out jointspace infection, as the MCP joint is violated in 70% of cases.
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Percentage of deep space infection?
Deep-space infections comprise 5% to 15% of all hand infections
abscess in the thenar region after a puncture wound will be blocked from moving ulnarly toward the small finger by the mid palmar septum
t
collar button abscess can moved proximally through the parona space
F collar button abscess originating
volar webspace and confined distally, because the strong palmar aponeurosis blocks infection from spreading proximally
collar button abscess spreads dorsally into the dorsal subcutaneous tissues
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Collar button abscesses
generally require volar and dorsal incisions for complete drainage;
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Thenar abscesses
can be managed with a dorsal incision and dissection between the
first dorsal interosseous and adductor pollicis muscles.
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transverse incisions within the webspace cause adduction contractures and should be avoided.
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There are two types of of necrotizing faciates
type 1, involving multiple anaerobic and aerobic bacteria, and
type 2, involving group A Streptococcus
and Staphylococcus sp
MRSA has been isolated in up
to 39% of cases
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Signs of hemodynamic
instability, such as hypotension, tachycardia, and altered mental status are indicative of septic shock.
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A classic sign of necrotizing fasciitis is
cloudy dishwasher drainage,
due to necrosis of the fascia.
Amputation must be considered in the setting of
advanced muscle necrosis and septic shock
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Patients should be placed in the intensive care unit if
there is any concern of hemodynamic instability
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Patients will
generally need extensive soft tissue reconstruction once infection is
cleared
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Because joints are avascular
immune privileged sites
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Haemophilus influenza (in children), and
Neisseria gonorrhoeae are the most common pathogens in septic arthrites
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The wrist joint is
opened via a longitudinal dorsal skin incision
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Automated pulse lavage is
avoided, because the excessive pressure can damage cartilage
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Mycobacteria are notoriously
difficult to culture; suspicion should be raised for mycobacteria when
rice bodies are found at time of debridement or granulomas are
found on pathology
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Sporotrichosis is a fungal infection more common in gardeners
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Herpetic whitlow causes a burning sensation for I or 2 days, followed by
erythema and blistering around the thumb of fingers
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Tzanck smear confirms diagnosis.
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Aggressive
debridement and unroofing of vesicles is ill-advised and can predispose patients to bacterial superinfection
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The standard
for diagnosing osteomyelitis is bone biopsy
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The ideal time to treat a hand infection is within the first 24 hours
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Any wound present for longer than 6 months should be biopsied
to rule out cancer,
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