Hand Infections Flashcards
How do you classify hand infections
- Acute vs chronic
- By anatomic site
- skin, subcut, deep space, tendon, muscle,
- By organism
- bac, viral, fungal, parasitic, protozoal
- By etiology
- trauma, human/animal bute, IVDU, immunocompromise, post-op
What special tests are used for identification of fungal, mycobacteria and HSV infections?
- Fungal: KOH, Giemsa, Silver stains
- Hyphae, spores, mycelia
- Mycobacteria/Nocardia: Ziehl-Niessen stain
- HSV: Tzank smear
What are treatment principles of hand infection
- Debridement
- I&D
- Splint, Elevation, Rest
- Antibiotics
- Early rehab
- For surgical Tx
- dont exsanguinated for tourniquet
- local takes longer to work
- plan for extension of incisions not over NV bundles
- plan for multiple washouts
- cultures from intraop samples
- Joints - avoid aspiration over area of cellullits
- Send joint fluid for cell count, C&S, Glc, protein
What are approaches to joints for washout of infection
- Radio carpal jt - b/w 3/4 compartments
- MCP jt - dorsal and split extensor
- PIP jt - midaxial, split TRL, protect central slip
- DIP jt - H or Y incision, protect TT
What are mimickers of infection to keep on DDX
- Gout/Pseudogout
- sent jt aspirate for crystals, Rheum referral
- Acute calcific tendonitis
- NSAIDs, Rheum referral
- FB
- Pyogenic granulosum
- excise and cauterize base
- Pyoderma gangrenosum
- macult->papule w raise violaceous borders, associated w UC.
- Do not excise - treat w steroids and wound care
- Spider bite
- brown recluse spider leads to ST necrosis
- Metastatc or 1’ tumor
- SCC BCC melnaoma KA
- DP primary site for bone mets (source thyroid, prostate, breast, lung, kidney, colon
What are the 3 potential spaces for infections in the hand and forearm
- Hand
- thenar
- hypothenar
- midpalm
- Forearm
- Paronas space
What are the 9 spaces (includes 4deep and 5 superficials)
DEEP
- thenar
- hypothenar
- midpalm
- Paronas
Superficial
- dorsal subcutaneous
- dorsal subaponeurotic
- interdigital webspace
- radial bursa
- ulnar bursa
Define boundaries of thenar space deep infection, symptoms/signs and treatment
THENAR SPACE
- Roof: D2 flexor sheath and palmar fascia
- Floor: Adductor fascia
- ulnar border: D3 MC vertical septum to palmar fascia
- radial border: confluence of AddP fascia and muscle at insertion to PP
Findings: thumb abducted, pain w opp/abd
Tx:
I&D across thenar crease and dorsal webspace
Define boundaries of midpalm space deep infection, symptoms/signs and treatment
MIDPALM - deep to flexors
Floor - Volar IO and MC 3,4,5
Roof - flexor sheaths 3,4,5 and palmar aponeurosis
Radial - vertical septum at D3 MC
Ulnar - hypothenar septum at D5 MC
Finding - loss of palmar concavity
Tx
I&D with incisoin from D3 webspace to pisiform
Define boudaries of Paronas space, findings and Treatment
- volar wrist b/w PQ and long flexors
- communicates w radial and ulnar bursa - horseshoe abscess-
- proximal extend to FDS insertion
What are complications of a hand infection
EARLY
- skin slough
- extension to adjacent structures - OM, SA, tendon rupture, vessel thrombosis
- amputation
LATE
- recurrence
- stiffness
- degenrative arthritis
What is your management of a felon
= subcutaneous abscess of the finger pulp
Compx: OM, skin/pulp necrosis
Tx - I&D - incise on non-dominent side, break apart septae, keep intact flexor sheath, Abx, pack tid
–> can also consider longitudinal incision over most pointing aspect of felon
What is your management of a herpetic whitlow
= vesicles 2’ to HSV1 (oral) HSV2 (genital)
Dx: Tzank smear of vesicle media or IF anti-HSV Ab
Tx: no I&D, dry gauze, topicla pancyclovir if immunocompromised, acyclovir if prodrome
What is your DDX of acute suppurative flexor tenosynovitis
- gout/psudogout
- inflammatory tenosynovitia
- herpetic whitlow
- felon
- abscess
What is your management of acute flexor tenosynovitis suppurativa
Early
- IV abx, splint elevate observe and reqeunt reassessment
Late
- Catheter irrigation - incise prox to A1 distal to A4, irrigate w tid dressing change
- ABX: ???
- Early ROM
What is your management of a dog/cat bite
History
tetanus
Rabies immunization
Culture
copious irrigation
delayed 1 wound healing
Xray to r/o FB
Abx: amox-clav (clavulin) OR if pen allergy, clindamycin + septra
What bacteria are associated w dog and cat bites?
DOG
- s. aureus, s. viridans
- bacteroides
- pasteurella multicoda GNB
- capnocytphaga canimorsus
CAT
- Pasteurella multicoda most common
plus similar to above
- cat scratch - rochalimaea henselea
What is your management of a human bite/fight bite
History
Tetanus
Culture
Xray for air in jt/FB
Clavulin OR if pen allergy, clindamycin + septra
I&D if joint involved, packing, delayed extensor repair
* most common pathogens
- aerobics: s. aureus, epidermidis, strep
- anaerobic: bacteroides, peptococcus, peptosctreptococcus, Eikenella corrodens GNR,
What is your management of a necrotizing fasccitis
- ABCs, ICU consult
- Culture wound/blood
- CBC, lytes Cr, LFT, CK, INR/PTT, lactate
- Or - debridement devitalized tissue, repeat OR 24-48hrs later
- IV abx - vanco+piptazo+clinda. Use 900mg IV q8h clinda for anaerobe, 4mu q4h penicillin for GAS
What are complications of septic arthritis
- Stiffness, adhesions
- OM
- degenerative arthritis
- boutonniere, mallet (pus erodes dorsally)
- amputation