Infections Flashcards

Question

How do you tx a Felon?

Answer 1

**Operative- incision and drainage** Due to risk of finger tip compartment syndrome

Answer 2

Approach: Keep incision **distal to DIP crease** -T o prevent DIP flexion crease contracture and prevent extension into flexor sheath. **Mid lateral approach** - see picture below- Indicated for deep felons with no foreign body and not discharging. Incision on **ulnar side** for digits **2,3 and 4** and **radial** side for **thumb** and digit **5** (non-pressure bearing side of digit) **Longitudinal approach** ( see pic) most direct) Indicated for superficial felons, foreign body penetration or visible drainage . AVOID FISH MOUTH INCISIONS-\> unstable fonger pulp DOUBLE LONGITUDINAL or transverse incision - injury to digital nerve and artery

Answer 3

Avoid violating **flexor sheath** or **DIP joint** to avoid spread into these spaces **Aim to Break up septa** to decompress infection and prevent compartment syndrome of fingertip don't forget gram stain and cultures Leave wound open to allow drainage!

Answer 4

Finger digitial tip necrosis Finger tip compartment syndrome Flexor tenosynovitis Osteomyelitis

Answer 5

**Dog and cat bites** **Cat bites** more frequently -needle like teeth -\> deep penetration wound so high suspicion required PC:Pain/swelling Wound to arm/ hand local or systemic sepsis

Answer 6

**Pasterella Multicoida**- 80% pt with **cat** bites Staph aureus Streptococcus alpha haemolytic Bacteriodes Corynebacterium

Answer 7

Dog bites- Cause **crush, puncture, avulsion, tears** and **abrasions** large dogs' jaws exert \>450lbs/ square inch more likely to cause **structural damage to nerves, vessels, joints** **Cats have fine sharp teeth-\> pentrating joints.** Puncture wounds that **close immediately-\> septic arthritis and osteomyelitis**

Answer 8

Thorugh cleaning of wound with saop or iodine - shown to dramatically reduce the devlopement of rabies in those bitten by infected animals ## Footnote **_Non op_** Copious irrigation, appropriate antibiotics, tetanus and rabies prophylaxis Antibiotics- amoxicillin/clavulanic acid effective against Pasteurella multocida, ce furoxime or ceftriaxone **Surgical debridment** if crush/devitialised tissue, abscess, bites to pup space, flexor tendon, joinspace, deep space of hand, septic arthritis.

Answer 9

Caused by a **rhabdovirus** common animal carriers include dogs, raccoons, bats, foxes Increased risk with open wounds, scratches/abrasions, mucous membranes fatal bites associated with large aggressive dogs, small children, head and neck bites prophylaxis is = human diploid cell vaccine and human rabies immunoglobulin Immobilise limb and elevate

Answer 10

Males more affcted then females Often occur around 3/4th MC after a fight- from direct punch another individual Actual human bite

Answer 11

Tooth pentrated capsule of MCPJ bacteria flora from mouth enter joint-\>infection Bacteria get trapped in joint as it is flexed and caught unde extensor tendon

Answer 12

Alpha haemolytic strep \* Staph aureus\* **Eikonella corrodens in 7-29%** \*= most common

Answer 13

Extensor tendon lacerations

Answer 14

1) Pain, swelling to hand with puncture wound to 3/4 MC Purulent discharge Pain with passive and active rom Test flexor and extensor tendons 2) xray hand to exclude any foreign bodies- teeth!

Answer 15

**Operative- Incision and drainage** **Debridement of wound** **Open capsule** **Leave wound open for drainage** **Gram stain and culture** Iv antibotics for 48 hrs then change to oral for 5-7 days -target organism - amoxicillin/clavulanic acid (augmentin)

Answer 16

**Pyogenic flexor tenosynovitis** Infection of the **synovial sheath** that surrounds the flexor tendon

Answer 17

1) **Penetrating injury** 2) **Spread** from felon, deep space infection, septic arthritis

Answer 18

**Staphylococcus aureus**- most common **Gram negative/ ****Anaerobic bacteria**= assoc HIV/ diabetic/ MRSA infections/ farmyard/ animal bites

Answer 19

**Horseshoe abscess** ## Footnote Many individuals have a connection between the sheaths of the thumb and little fingers at the level of the wrist I nfection in one finger can lead to direct infection of the sheath on the opposite side of the hand resulting in a condition known as a "horseshoe abscess'

Answer 20

See pic below Tendon sheaths **function to allow glide of tendons, provide nutrtion by bathe in synovial fluid** and **protect** the **flexor tendons** They extend **DIPJ- midpalm** in **index, middle and ring fingers** **From DIPJ to wrist ( ulna bursa) in little finger** **from IPJ to wrist ( radial bursa) in thumb**

Answer 21

**Kanavel signs** - 4 signs in total ## Footnote 1) **Flexed position** of involved digit 2) **Fusiform swellling** of digit 3) **Tenderness** to palpation over tendon sheath 4) Marked **Pain on passive stretch/extension**

Answer 22

**Increase pain** 48 hrs- localised to palmar aspect of digit ## Footnote **Swelling**

Answer 23

Xrays no use MRI cannot distinguish infectious flexor tenosynovitis from inflammatory but may help determine the extent of the ongoing process

Answer 24

_Non op_: in **early intervention**= Admit, elevation and iv antibiotics, close obeservation- surgery if no improvement in 24hrs _Surgery_= incision and drainage of flexor sheath iv antibiotics following op to avoid **ADHESIONS** in flexor tendons

Answer 25

_**Palmar incision**: _ - transverse incision is made just **proximal to distal palmar crease,** over the infected tendon; - spread thru the palmar aponeurosis; - make incision just **proximal to A1 pully** and enter into sheath; _**Distal incision:** _ - finger incision may be made either dorslateral at level of middle phalanx or directly on palmar surface at this level; - incision can also be made in the **distal flexor crease** of digit; - distal sheath is exposed thru ulnar midaxial incision & opened; - enter sheath between **annular pulleys**, **insert small paeds feeding **catheter- (size no. 5 Fr) or 16 gauge catheter and irrigate +++ Iv antibiotics for 48 hrs then oral 2 weeks Hand physio post to prvent adhesions

Answer 26

Brunner lines in finger to open skin then incise tendon sheath prox A1 pulley and annular pulleys distally According to Hand Surgery Update 3 2003, Trumble states, open sheath irrigation has been replaced largely by closed sheath irrigation. These authors cite a retrospective study that showed **no statistical difference in resolution of infection using open sheath irrigation or closed sheath** irrigation, however, there was a trend towards more **frequent complications** and reoperations in the **open** drainage group.

Answer 27

possibly a **Deep space infection** **Hypothenar, Thenar and Midpalmar space** other DD not in this picture **Collar button infection- ( abscess in webspace between fingers)**

Answer 28

Thenar= A bursa (potential space) just palmar to **adductor pollicis** and dorsal to flexor tendons. Separated from midpalmar potential space by a fascial septum Midpalmar= dorsal and radial to hypothenar space Hypothenar space= palmar to 5th MC, dorsal and radial to hypothenar fascia, ulnar to hypothenar septum

Answer 29

**Thenar** hx of penetrating injury to hand Worsening swelling and pain O/E pain on thumb flexion- thenar space finger pain on little finger flexion- hypothenar pain on flexion middle, ring index- midpalmar

Answer 30

_Operative-_ incision and drainage ## Footnote Technique Use volar and dorsal incisions for collar button abscesses Avoid skin in actual web space **Thenar space** release- dorsal incision (can spread to involve 1st dorsal interossei) or palmar incision **Midpalmar release**- **transverse incision across palm** **webspace infection- incisions dorsal and volar to alow adequate drainage. Not transverse -\> contractures**

Answer 31

Marine workers Hand and wrist in 50% of cases

Answer 32

Incubation period 2 weeks to 6 months Average time to diagnosis and tx is 1 year

Answer 33

**Mycobacterium marium**\*- injuries in marine environments/aquariums **mycobacterium avium**-intracellulare\* \*most common **M. kansasii** - i soil

Answer 34

Symptoms:cutaneous rash with discomfort signs: papules, ulcers and nodules- indistinguishable to tuberculous mycobacterial infection Dx by Culture requiring **Lowenstein-Jensen culture agar at 30-32 degrees**

Answer 35

_NON OP _If diagnosed early with **ethambutol,** **tetraycline**, **trimethoprim-sulfamethoxazole**, **clarithromycin, azithromycin ** add rifampin if osteomyelitis present surgical debridement and antibiotics for later disease

Answer 36

Fungal infection serious in immunocompromised patients Rare but common to have it in areas of macerated skin.

Answer 37

**Cutaneous** - involving nail bed-**Onychomycosis** **Subcutaneous** - **sporothrix schenckii** from rose thorn prick **Deep**-orthopaedic manifestation= tenosynovial septic arthritis, osteomyelitis

Answer 38

**Onychomycosis** A Superficial fungal infection of the nail **Trichophyton rubrum**=\>a destructive nail plate infection **Candida**=\>chronic infection of nail fold

Answer 39

**Topical antifungals** **Nail plate removal** systemic **griseofulvin** or **ketoconazole** if retractible disease

Answer 40

**Sporothrix schenckii** A common soil bacteria Rose thorn in classic mechanism of subcutaneous transmission

Answer 41

A small papule where pentration of skin made then additional lesions in region of lymphatic tissue ( see pic) ## Footnote S schenckii is isolated at room temperature on **Sabouraud dextrose agar**

Answer 42

Oral **itraconazole** for **3 to 6 months**

Answer 43

**Histoplasmosis**-\> sublclnical symptoms/ tenosynoval - found in rivers-tx amphotercin B, surgical debridment and tenosynovectomy **Coccidiomycosis- \> arthritis/synovitis/ periarticular arthritis** **tx with amphocterin B and surgical debridement **