Hand Infection

By admin Last updated Sep 15, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Hand Infection

Michael M. Linder

Andrew Harcourt

Basics

Description

Infection present in any structure in the hand
Generally caused by penetrating trauma, but any trauma can introduce pathogens.
Early recognition is key, as infections caught early are amenable to splinting, elevation, and rest.

Risk Factors

Diabetes mellitus: More likely to have gram-negative infections and are more susceptible to infection in general
Immunocompromised: More susceptible to N. gonorrhea and candidal infections
Sexually transmitted disease exposure: Increased incidence of flexor tenosynovitis caused by disseminated N. gonorrhea
Tropical fish aquarium injury: Exposure to Mycobacterium marinum

Etiology

Paronychia: Infection involving the tissue surrounding the nail:
- Acute: Staph and strep
- Chronic: Commonly due to Candida
- Children: Anaerobes or fungal secondary to thumb sucking or nail biting
Felon: Infection of the distal pulp space of the finger:
- Primarily staph
Herpetic Whitlow: Autoinoculation of broken skin with type 1 or 2 herpes simplex virus
Flexor tenosynovitis: Infection in one or more of the flexor tendon sheaths:
- While flexor tendon sheath anatomy varies greatly, generally the tendon sheath of the index, middle, and ring finger extends from the distal phalanx to the distal palmar crease and is isolated.
- The tendon sheath of the 5th digit extends from the distal phalanx and communicates with the ulnar bursa, while the thumb tendon sheath extends from the distal phalanx to the radial bursa.
- Once present, infection can spread easily to all communicating spaces.
- Most commonly staph and strep
Clenched fist injury: Infection following human bite or fight injury to the dorsum of the hand:
- Typically involves both anaerobes and aerobes
Palmar space infection: Can be isolated to the thenar and hypothenar spaces, or midpalmar space:
- Usually staph or strep
- Can be secondary to high-pressure injection injury

Diagnosis

History

A careful history should be taken to determine mechanism of injury, past medical history, and other associated risk factors.

Physical Exam

A complete physical exam is indicated, with particular attention to the neurovascular status and function status of the affected structures.
Paronychia: Pain and swelling at the edge of the nail
Felon: Significant pain and swelling of the distal pulp
Herpetic Whitlow: Abrupt onset, pain out of proportion to exam, small clear vesicles early, which coalesce
Flexor tenosynovitis: Kanavel's signs:
- Fusiform swelling
- Partial flexion at rest
- Excessive uniform tenderness along the tendon sheath
- Pain with passive extension
Clenched fist injury: Laceration over metacarpophalangeal (MCP) joint, swollen and erythematous dorsum of the hand
Palmar space infections: Redness, tenderness, and fluctuance

Diagnostic Tests & Interpretation

Paronychia: Culture if incision and drainage performed
Felon: Radiographs to evaluate for osteo or foreign body
Herpetic Whitlow: Tzanck smear or viral culture can confirm diagnosis, but are rarely needed.
Clenched fist injury: Radiographs are indicated to evaluate for fracture, subcutaneous gas, or foreign body.
Palmar space infections: Radiographs to evaluate for foreign body and fracture

P.291

Treatment

Paronychia:
- Early infections can be treated conservatively with antibiotics, elevation, and rest.
- If fluctuance is present, the eponychium may be sharply elevated and irrigated; if infection is evident under the nail, the proximal 1/4 of the nail is removed.
- 1st-generation cephalosporin, clindamycin if gram-negative organism is suspected
Felon:
- May be drained with either a lateral incision or vertical volar incision; knowledge of neurovascular structures is key when making a lateral incision.
- Care is taken to debride all purulent material and the wound packed with sterile gauze for 24–48 hr
- Antibiotic coverage should include methicillin-resistant Staphylococcus aureus (MSRA)
Herpetic Whitlow:
- Self-limited, may be treated with antivirals if started in 1st 48 hr
- Recur 30–50%
Flexor tenosynovitis:
- Early infections may be amenable to conservative treatment with IV antibiotics, splinting, elevation, and rest.
- All rings should be removed if tenosynovitis is suspected.
- If no improvement in 12–24 hr, surgical consultation is mandated.
Clenched fist injury:
- All wounds should be irrigated and explored for signs of penetrating trauma, retained foreign body, extensor tendon injury or metacarpophalangeal (MCP) joint capsule damage.
- If seen in 1st 24 hr and there is no evidence of secondary injury, may be irrigated and placed on prophylactic antibiotics, typically amoxicillin-clavulanate and recheck in 24 hr
- Do not primarily close wound.
All other injuries should be considered for hospital admission and IV antibiotics.
Palmar space infection: Urgent consultation for evaluation and debridment

Pre-Hospital

Early consultation/admission is indicated for flexor tenosynovitis, infections in the deep structures of the hand, and complicated clenched fist injuries:

IV antibiotics and operative drainage are generally indicated for all of the above.

Ongoing Care

Follow-Up Recommendations

Paronychia and felon should be followed up at 24 hr if irrigation and drainage was done.

Additional Reading

American Family Physician. Common Hand Infections. 2003;68:2167–2176.

American Family Physician. Hand and wrist injuries: part II. Emergent Evaluation. 2004;69:1949–1956.

Townsend: Sabiston textbook of surgery, 18th ed.; Chapter 74—Hand surgery, infections.

Canale & Beaty: Campbell's Operative Orthopedics, 11th ed. 2006.

Antosia RE, Lyn E. The hand. In: Rosen P, et al., eds. Emergency medicine: Concepts and clinical practice. 4th ed. St. Louis: CV Mosby, 1998:625–668.

Brown DM, Young VL. Hand infections. South Med J. 1993;86:56–66.

Hausman MR, Lisser SP. Hand infections. Orthop Clin North Am. 1992;23:171–185.

Codes

ICD9

686.9 Unspecified local infection of skin and subcutaneous tissue