Infections of the hand Flashcards
Cellulitis
Pioneer: Dr. Alan Kanavel
most common Staphylococcus / Streptococcus
subcutaneus - S. aureus, ß-hemolytic Streptococcus
from distal to proximal (entry point)
12 - 24h antibiotic - than surgery
specific:
- staphylococcla scalded skin syndrome (exfoliative toxin producin staphylococcal) - mostly children
- necrotizing fasciitis: dish-water fluid on the fascie
mixed species:
bite wounds / diabetes
animals: Pasteurella multiocida
humans: Eikonella corrodenses
n
MRSA
strain - - 1961 - United Kingdom
HA-MRSA (hospitals)
CA-MRSA (community associated) (Panton - Valentine - Leukocitin (PVL) - Toxin - tissue necrosis
“snake bite infection” - central skin necrosis - surrounding erythema
DD: inflammatory disease - gout - conservative theray - ggf. observation for 24-48h
if there is no improvement - surgical therapy
Acute paronychia
bacteria between nail fold and nail plate covered from the eponychium
mostly S. aureus
abscess - nailfold - nailplate - pus under eponychial fold - special: run around infection
treatment:
conservative: soaks with warm water, oral antibiotics, maybe cut the thin layer of the eponychium to drainage the abscess
surgical treatment depends on where the abscess is and how great
DD: herpetic whitlow (no surgery - Virämie!!!)
7 to 10 days antibiotics
daily soaks in lavasept / povidone-iodine - 3 times a day
splinting in acute situation
early finger range of motion
careful observation - Felon!!!
Robbins 1950 - 13,5% with acute paronychia develops a Felon through a small sinus from the side of the nail to the palmar pulp
chronic paronychia
middle aged woman - w:m - 4:1
repeating contact to bacteria - whorse with diabetes and psoriasis
gram pos. cocci
gram neg. rods
candida
myobacterial species
treatment:
most common - eponychial marsupialization or swiss roll technique
maybe nail excision partly or total
xeroform gaze
postop: soaks in lavasept / povidone - iodine 3 times a day
secondary wound healing about 4 weeks
complications: nail deformity growth, scar sensitivity is most common, oral antibiotics for 2 weeks
Recurrence:
nail plate removal and Remarsupialization
felon (Panaritiium)
subcutaneous abscess of the pulp
(except: superficial infections of the most distal part “apical infections” - palmar pad not involved)
multiple 15 - 20 septal closed compartments
mostly S. aureus
(immunsupressive / diabetes: gram neg. species)
15 - 20% of all hand infections - sometimes penetrating injury
cave: osteomyelitis - pyogene arthritis
Kanavel: “closed sac connective tissue framework, isolated and different from the rest of the finger”
multiple vertical trabeculous framework - swelling, cellulitis - development of an abscess in “closed sac”
if untreated: ischemia first to the periosteum and the bone - than the skin
treatment:
incision when the pulp is tender
incision planning
wick drainage for 2-5 days
antibiotics for 5-7 days (if bone is involved longer antibiotic therapy)
complications:
hypersensitivity, scars - pulp instability - (destroyed trabecolous framework) - resolve in 6 to 12 month
pyogenic flexor tenosynovitis
species:
s. aureus, ß-hemolytic streptococcus, Pastorella multiocida
immunsuppressive: E. corrodens, Listeria monocytogenes, gram pos. and gram neg. infections
haematogen very rare: Neisseria gonorrhoe!!!
Kanavel signs:
- semiflexed finger
- swelling / enlargement (97%)
- excessive tenderness in the flexor sheat
- pain when passively extend the finger (72%)
blood and radiographis
DD: herpetic withlow, felon, pyarthrosis, local abscess, inflammatory disease (RA, gout, aseptic flexor tenosynovitis)
if the diagnosis is not clear maybe NSAID for 24h - careful observation
pertinent anatomy:
flexor sheath - double layer - visceral and parietal - metacarpal head to proximal to the DIP
thumb and small finger have connections to the radial and ulnar bursa - connection to the paraona space - (fascia of the pronator quadratus and the conjoined FDP flexor sheath) - HORSESHOE ABSCESS
when bacteria in flexor sheath - tendon synovial fluid becomes nutritial source for the bacteria
pressure increases - 30mmHg in 50% of all cases (Schnall and colleagues) - ischemia through the vinculae with following tendon necrosis
Treatment:
seen in the first 24h maybe conservative treatment with antibiotic, splinting and elevation the hand, clinical observation for the next hours - immunsuppressive patients should treated surgical (fluid aspiration befor antibiotics)
surgical:
different approaches - lateral mid incision to explore the whole flexor tendon sheath, also possible closed sheath irrgation (48h with 50ml every two hours - very painful for the patient)
wide open midlateral excision to the flexor sheath - opening and irrigation - incision dorsal to the Cleland’s ligaments - wick drainage to keep the distal and proximal wound open
postop: intravenous antibiotics, pain management and early finger motion - first dressing change after 8 to 12 hours - soaks in dilute povidone-iodine solutation 3 times a day - repeat surgical debridement and irrigation if Kanavel signs do not resolve - sedondary wound healing - when swelling decreases - steri strips can be used to bring the wound edges together
poor outcome (Pang and associates) - 5 criteria
- age greater than 43
- diabetes mellitus, peripheral vascular disease or renal failure
- presence of subcutaneous purulence
- digital ischemia
- polymicrobial infection
tendon necrosis: tendon transplantation is not very good - bad outcome (amputation especially it the littler or second finger is involved)
severe flexor sheath infections with pyarthrosis should be treated with amputation
Radial and ulnar bursal infections
radial bursa:
continuation of the thumb flexor tendon sheath from the metacarpal joint - 1-2cm proximal of the retinaculum flexorum - very constant
ulnar bursa:
continuation of the small finger flexor tendon sheath from the metacarpal head - lying on the metacarpal IV shaft and the basis of metacarpal basis III und IV - through the carpal tunnel to the parona space - here is contact to the radial bursa
HORSESHOE ABSCESS!!!
often variations of the contact of the flexor tendon sheath - so a clinical examination fo all flexor tendon sheaths is necessary
Treatment:
as flexor tenosynovitis - irrgations with 600 - 800ml saline from proximal to distal - wounds stay open - with drainage
deep space infections
hand: 3 defined potential spaces - thenar space, midpalmar space, hypothenar space
foream: 1 defined potential spaces - parona space
mostly penetrating injury
swelling of the hand - tight fascia palmar limiting the swelling - loose tissue dorsal with swelling on the dorsal aspect of the hand (thenar and midcarpal space)
hypothenar abscess have no dorsal swelling
thenar space:
most common deep palmar space infection, adduction and opposition causes pain - if the abscess goes dorsally through adductor pollicis and first interosseus - we call it dumbbell or pantaloon abscess
midpalmar space:
uncommon - palmar configuration becomes convex
hypothenar space:
extremely rare -
midcarpal and thenar space are dorsally to the flexor tendons and volary to the metacarpal and interosseus muscle fasciae - divided by the midpalmar (oblique) septum - from the palmar fascia to the volar diaphyseal ridge of the 3. metacarpus
deep subfascial space infections:
dorsal subcutaneous space, dorsal subaponeurotic space, interdigital web space (track volary and dorsally - so called “collar button absecesses”)
treatment:
dorsal subcutaneous and dorsal subaponeurotic space - longitudinal incision
collar-button-abscess:
incision volar and dorsal - different approaches
Parona space:
continuity to the midpalmar space - digital flexion is painful -
postop. care:
splinting - wounds open - soaks - IV antibiotics - early motion of the fingers - reevaluation after 24 to 36h in the OR,
septic arthritis
purulent exsudate in a joint - mostly from penetrating trauma
s. aureus and streptococcal species
immunesuppressive: gram neg., anaerobic and mixed species
hematogenous origin suspicion of a gonococcal infection
bactericidial enzymes from leukocytes destroy the proteoglycan matrices and the collagen of hyaline cartilage - pressure increases - pressure necrosis of the hyaline surface - pus through the capsule to the skin or through the subchondral bone to a osteomyelitis
DIP: mucous cyst, felon, paronychia, pyogenic flexor tenosynovitis
PIP: purulent flexor tenosynovitis
MCP: clenched-fist injury
DD: gout, pseudogout, RA, SLE, psoaritic arthritis, acute rheumatic fever, sarcoidosis, Reiter’s syndrome
wrist: open or arthroscopic
MCP: mostly clenched-fist injury, good irrigation, capsule and wounds are left open
PIP: side skin incision - transversed retinacular ligament is incised - incision of the accessory ligament followed by capsulotomy - both sides gives a good outcome - wounds are left open
DIP: dorsal H-incision or dorsal reversed Y-incision - protect the tendon insertion - irrigation - wounds are left open
postop. care:
early range of motion - especially when doing soak to do mechanical lavage - IV antibiotics for 3 to 4 weeks - other possibility is to use IV antibiotics for 1 - 2 weeks and than switching to oral antibiotics for 4 - 6 weeks
little stiffness is normal (study of 33 infections - only 13 patients achieved full restoration)
complication: septic Boutonière and Mallet deformity
osteomyelitis
infection of the bone - 1 to 6% of all hand infections - most common is the distal phalanx
penetrating trauma is the most reason, hematogenous infection occurs in children - very rare - only 1 of 62 infections occurs in the hand
deef infections of the bone after open fractures within 11% - mostly S. aureus - significant pin track infections from 0,5 to 5%
classification:
anatomic sites of infections and physiologic classes of the host
anatomic site:
1 - medullary osteomyelitis
2 - superficial osteomyelitis
3 - localized osteomyelitis
4 - diffuse infection
physiologic class
A - Normal host with good immune system
B - local or systemic compromise
C - markedly compromised host
all patients have local signs of inflammation but only 33% had fever and leukocytosis
only 5% have radiographic signs in the initial stadium - most radiographic findings after 2 to 3 weeks - such as - metaphyseal rarefaction, osteopenia, osteosclerosis, periosteal reactions
treatment:
early diagnosis and therapy is important for functional outcome, radical debridement with wounds left open, distal phalanx osteomyelitis is treated with amputation - prolonged IV antibiotics over 4 to 6 weeks
animal bites
dog bites more common than cat bites - problems with cat bites because of the small teeth inocculate the species deep into the tissue
S. aureus
Streptococcus viridans
Pateurella multocida very frequent species (first infection in the first 12-24h mostly P. multocida)
cats: Francisella tularensis
dogs: very rare - Capnocytophaga canimorsus
Streptococcus moniliformis - rat-bite-fever - eruptive fever with blisters and polyarthritis and a spectacular desquamation (abschuppung) of the hands
marine organism
Mycobacterium marinum - commonly associated with aquatic infections - generally chronic infections
other species:
Staphylococcus, Stretococcus, Pseudomonas, Aeromonas, Enterobacter
fresh and brackfish - Aeromonas species - mortality of up to 27%
Vibrio vulnificus and Vibrio damsela
can make local infections or septicemia with the food over the gastrointestine tract - disseminated infections leading to necrotizing fasciitis - mortality rate (67 - 88%) - local infections are self-limiting - but worse development is possible
Leeches
pseudomonad Aeromonas hydrophilia - cultured from 18% of flaps where Leeches were used - broad spectrum prophylactic antibiotics when using leeches
Human bites
4 mechanism for infection from human bites
- nail biting or secondary sucking on bleeding wounds
- traumatic amputation secondary to a bite wound
- full-thickness bite wounds into various parts of the hand
- fight bite
clenched fist injuries are difficult to treat and the patient comes to the hospital in the fact that there is pain, swelling and purulent fluid or redness
wide wound opening - mostly Eikonella corodenses - and irrigation without pulse - antibiotics against aerob and anaerob species - other species are Staphylococcus and Streptococcus species
complications:
septic flexor tenosynovitis, septic arthritis, osteomyelitis, stiffness and pain, toxic shock syndrome and death have been reported
Prosthetic/Implant infections
treatment with implantat removal and removal of nonviable tissue
aseptic nonunion or aseptic loosening of the prothesis - comes through bacterial biofilms
prosthetic joint replacement mostly seen with rheumatoid arthritis - although immunocompromised only infections from 0,5 to 3% - prothesis removal and removal of necrotic bone - reimplantation is rare
silicone rods - infections about 2-4%
biofilm species secrete a exopolysaccharide matrix which isolated the bacterial colonies from the surrounding tissues and so the bacteria is protect from the host defense mechanism - slow growth with difficulties in culturing an organism - bacteria or fungi - biofilm can release bacteria in form of “planktonic states” - antibiotic are only effective against planktonic states
only treatment - complete removal of implant and nonviable tissue - antibiotic spacers and iv antibiotics for not less than 6 weeks
