HAND INFECTIONS Col. T.L.B. le Roux Maj. A.J. Julyan Department of Orthopeadic Surgery 1 Military Hospital Department of Orthopeadic Surgery 1 Military Hospital2012 From : The Hand Book (Chapter 5)

INTRODUCTION  One of the most serious hand injuries  Most important cause of hand swelling  Neglect > involvement rest of hand  Adhesions + loss of vital structures  Loss of function  Amputation (Partial > total)

MANAGEMENT  Correct and early diagnosis  Correct, early and aggressive surgical and medical management  Early mobilization and rehabilitation

PATHOPHYSIOLOGY  Organisms via various routes  Direct penetration, haematogenous, anatomical tissue planes  Local tissue reaction and oedema  Tissue tension > impaired circulation  Microvascular thrombosis and ischemia  Abscess formation

AIM OF TREATMENT  Preserve good circulation  Arrest microbial proliferation

PRINCIPLES OF TREATMENT  Early decongestion by abscess drainage  Appropriate dressing to allow draining  Splinting of the hand in the correct physiological (functional) position  Elevation to reduce swelling  Appropriate antibiotics when applicable  Hand baths  Early mobilization and rehabilitation

BACTERIOLOGY  Most common : Staphylococcus aureus  Other 50% : Streptococci, Gram negative organisms, fungi, TB

SYMPTOMS + SIGNS  Hallmarks of inflammation: Throbbing pain Throbbing pain Raised local skin temperature Raised local skin temperature Redness Redness Tenderness Tenderness Swelling Swelling  Severity and expressiveness: Type of injury Type of injury Type of organism Type of organism

SPECIAL INVESTIGATIONS  Sound clinical judgement – most important  X – rays : osteitis or septic arthritis  Bacteriological studies Mixed, chronic infections Mixed, chronic infections Extraordinary ( TB, Fungal ) Extraordinary ( TB, Fungal )  Histology  Serology : Gonococcus, Syphilis, Brucella  Biochem : Gout

DIFFERENTIAL DIAGNOSIS  Aseptic inflammatory conditions Gout, OA, De Quervain’s, non-infectious tenosynovitis Gout, OA, De Quervain’s, non-infectious tenosynovitis  Allergic conditions  Peripheral vascular disease, peripheral nerve disease, diabetes mellitus Poor blood supply, slower healing, resistant to antibiotics Poor blood supply, slower healing, resistant to antibiotics  Insect bites

TREATMENT - Anaesthesia  Necessary for thorough debridement and wound toilet  Children : General anaesthetic  Adults : General or regional ( brachial plexus, axillary, subacromial )

Treatment – Bloodless field  Mandatory  Elevate the hand for 30 – 60 seconds  Dangerous to use Eschmarch or other kind of bandage to accomplish a bloodless field  The septic process could be squeezed proximally

Treatment - Incision

Treatment - Dressings  Plugs should never be used  One layer of paraffin gauze – packed with loose gauze swabs  Dressings removed within 24 hours  Followed by hand baths  Avoid Eusol and Saline > tissue damage  Rather Plasmalyte B, Ringers

Treatment - Dressings

Treatment - Debridement  Drained abscess – cleaned out – tip of finger  Soft tissue adhering – must be removed  Prevents chronic discharge

Treatment - Splinting  Splint the postoperated hand in a functional position  Reduces the swelling, relaxation of lymphatics and veins  Alleviates pain  Functional (Physiological) position Wrist in 30 degrees of dorsiflexion Wrist in 30 degrees of dorsiflexion MP joints in 90 degrees of flexion MP joints in 90 degrees of flexion Interphalangeal joints in full extension Interphalangeal joints in full extension First webspace in full abduction and extension of the first metacarpal (open) First webspace in full abduction and extension of the first metacarpal (open)

Treatment – Hand baths  Very important for mechanical cleaning  Large bowl with lukewarm water and soap  Patient cleans with his other hand  Closed with dressing afterwards  Repeated 3-4 times daily  Use Hibidil or Savlon  Start immediate hand therapy after dressings

Treatment - Swelling  Early mobilization – reducing swelling – regaining full function  Not later than 12 – 24 hours after surgery  Enemy of the hand is oedema  It inevitably leads to fibrosis and stiffness  Elevate above the level of the hart

Treatment – Antibiotics  In general not necessary – source removed  Take swabs with initial debridement  If any doubt exists – appropriate A/B  Also indicated in early stages of infection  When pus collection is evident the treatment is surgical drainage not A/B

Treatment – Analgesics  These are painful conditions!  Effective pain relief – enhances early mobilization  Be aggressive and break the pain cycle  Combination of Opiate, NSAID, Sedative  Most also available IVI

Complications  Chronicity Diabetes, Gout, peripheral vascular disease Diabetes, Gout, peripheral vascular disease  Persistent drainage Incomplete drainage, foreign bodies, osteitis and soft tissue sequestrum Incomplete drainage, foreign bodies, osteitis and soft tissue sequestrum Leads to persistent drainage Leads to persistent drainage Initial debridement shouldn’t leave behind any devitalized, dead or foreign tissue Initial debridement shouldn’t leave behind any devitalized, dead or foreign tissue

Complications

Complications  Joint stiffness Delayed onset of mobilization Delayed onset of mobilization Incorrect dressings, pain, oedema Incorrect dressings, pain, oedema  Spreading infection Delayed treatment Delayed treatment  Gas gangrene Farm or outdoor related injury Farm or outdoor related injury Aggressive debridement, rinsing and A/B Aggressive debridement, rinsing and A/B

SPECIAL INFECTIONS  Streptococcal infections  Human bites  Osteitis  Septic arthritis  Lymphangitis  Necrotizing fasciitis  Pyogenic Granuloma

SPECIAL INFECTIONS  Postoperative wound infection  Burns  Paronychia and eponychia  Felon or pulp space infection  Palmar space infections  Septic tenosynovitis  Leprosy, TB, Mycobacterium Marinum  Dorsum hand and others

Streptococcal infections  Rapidly spreading cellulitis without abscess formation  Epithelium is elevated by a collection of serous fluid – blister  Treatment : Remove elevated epithelium Remove elevated epithelium Paraffin gauze Paraffin gauze Appropriate A/B Appropriate A/B

Streptococcal infections

Human Bites  Most septic and most serious bite  Mixed flora – extremely pathogenic to normal tissue  Tips of fingers, knuckles  “ Fight bite” – Attacker with finger in full flexion Attacker with finger in full flexion Presents as patient fingers in extension Presents as patient fingers in extension Superficial puncture wound Superficial puncture wound Much deeper into MP joints – “closing off “ Much deeper into MP joints – “closing off “

Human bites  Treatment aggressive – debridement wide and with fingers in flexion and extension  A/B : Triple therapy – Penicillin, Aminoglycoside, Metronidazole  Can still cause osteitis  Sometimes partial amputation only way to stop spread of infection

DOGBITE

DOGBITE

Septic Arthritis  Should be distinguished from gouty arthritis  Arthrotomy and debridement  Synovectomy and irrigation  Appropriate A/B  Joint mobilization

Lymphangitis  Red streak on the dorsum of hand or volar aspect of forearm  Streptococcal origin  Elevation  Splintage  IVI Penicillin

Necrotizing Fasciitis  Causitive organism : Clostridia family – mostly Perfringens  Sometimes Streptococci  Overwhelming, fast spreading, with systemic toxic symptoms  Radical surgical debridement and re- debridement  IVI A/B : Start on high doses Penicillin

Pyogenic Granuloma  “ Proud flesh “  Overgrowth of granulation tissue  Chemical cauterization : Silver Nitrate Silver Nitrate Iodine Iodine  Surgical removal and skin grafting  Send for histology

Pyogenic Granuloma

Postoperative Wound Infection  Prevention : Aseptic techniques Aseptic techniques Gentle tissue handling Gentle tissue handling Preservation of blood flow Preservation of blood flow Prevention of oedema Prevention of oedema  Treatment : Removal of sutures Removal of sutures Hand baths Hand baths A/B A/B

Paronychia  Early stages – elevation and A/B  Collection of pus – drained  Remove lateral aspect of nail – can form sequestrum  Osteitis

Eponychium  Infection of the nail fold in the Lunula region  Elevated part of nail to be removed by two lateral incisions  Chronic – Candida or Monilia

Pulp space infection (Felon)  Detrimental to blood supply  Osteomyelitis

Felon

Palmar space infections

Palmar Space Infections  Webspace, thenar or midpalmar  Cause : Septic callus, septic blister, tenosynovitis, direct inoculation Septic callus, septic blister, tenosynovitis, direct inoculation  Treatment : Approach webspaces directly Approach webspaces directly Blunt dissection Blunt dissection Evacuate the abscess Evacuate the abscess

Septic Tenosynovitis  Serious infection  Massive oedema of finger  May spread via synovial sheaths  Kanavel’s four cardinal signs  Early incision and irrigation  Hand is elevated  Mobilization is delayed for 3-4 days

Kanavel’s four signs  Slight flexion of finger  Swelling  Pinpoint tenderness over sheath  Pain on passive extension

Septic Tenosynovitis

Leprosy  Staged and rare infection  Inflammatory stage – leads to an absolutely stiff hand  High doses Cortisone  Loss of sensation – burns and injuries  Osteomyelitis can follow  Drugs : Dapsone, Rifampicin, Clofazimine

Tuberculosis  Not uncommon in the wrist joint  Diagnosis difficult  Mostly confirmed with synovial biopsy  Treatment : Synovectomy Synovectomy Splintage Splintage Rehabilitation Rehabilitation Drug regime Drug regime

Miscellaneous  Mycobacterium Marinum Fishermen, spreads rapidly Fishermen, spreads rapidly Surgery, Rifampicin Surgery, Rifampicin  Dorsum hand infections Whitlow Whitlow  Fungus Palm trees, Bougainvillea Palm trees, Bougainvillea  Erysipelas

CONCLUSION  Serious conditions  Treat timeously and with respect  Permanent complications – huge impact on life, work and limb  Treat or refer as emergencies

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