Chapter 34- Hand infections

Question 1

What is the most common organism causing hand infections and what is the pathogenesis?

Answer 1

S. aureus- Produces a powerful exotoxin which causes thrombosis of vessels and necrosis or sloughing of surrounding tissues. THis slough liquefies, pus discharges externally or tracks in different directions

Question 2

Other than S.Aureus, what other organisms are responsible for infections in the hand?

Answer 2

• Hemolytic streptococci
• E. Coli
• In human bites, mixed organisms enter the tissues

Question 3

What is the most common mode of infection in the hand

Answer 3

innoculation eg pinprick, fine metallic splinters in industry

Question 4

What is the danger of injudicious probing or blind use of forceps in the terminal phalanx?

Answer 4

Can spread infection from closed pulp space into the tendon sheath of the Flexor digitorum profundus

Question 5

Where can finger infection spread to?

Answer 5

• May spread proximally into the palm, deep to the palmar fascia
• Less frequently spreads up the lumbrical canal into the web spaces

Question 6

Where may the swelling be in infections of the web spaces and palm?

Answer 6

Because the skin and subcutaneous tissues on the dorsum of the hand are loose and elastic- they can easily become oedematous

Question 7

which are the minor infections of the hand

Answer 7

• Paronychia
• Distal pulp infection
• Web space infection
• Superficial non specific infections

Question 8

Which are the major infections of the hand

Answer 8

• Tendon Sheath infection
• Deep palmar space infections
• Human bites

Question 9

How does one counteract the stiffness of the hand caused by the exudate resulting from the infection?

Answer 9

• Early control of infection
• Elevate hand
• Begin movement as soon as possible

Question 10

What are the principles of management of a hand infection- specifically for removing the cause?

Answer 10

• Anaesthesia- digital blocks, regional anaesthetic, IV blocks, general anaesthesia. Avoid ring blocks
• Bloodless field- Exsanguination of limb by elevation adn use of tourniquet
• Surgery- Complete removal of all dead and necrotic tissues, foreign material and pus. Wound is left open, dry dressing is applied and the wound is inspected and reassessed 2 days after surgery

Question 11

In which situations should antibiotics be used in a hand infection

Answer 11

• Suspected but not established infection
• Minor hand infections where the infection has extended beyond the boundaries of the localised abcess
• Major infections

Question 12

What is the sequence of spread in minor hand infections

Answer 12

surrounding cellulitis - lymphangitis - lymphadenitis- bacteraemia or septicaemia with pyrexia

Question 13

What is the ‘safe’ position of the hand when splinting an infected hand

Answer 13

• Wrist extended to 30 degrees
• MPJs fully flexed
• IPJs fully extended
• Abducted thumb

Question 14

When should active movement of an infected hand be commenced

Answer 14

As soon as the infection appears to be under control, with diminishing oedema, early wrinkling of the skin and decreased pain

Question 15

What are the principles of management of a hand infection- specifically regarding treating the effects?

Answer 15

• Antibiotics
• Splinting vs movement
• Elevation

Question 16

Treatment of acute paronychia

Answer 16

• Antibiotics
• Massaging open the nail fold with warm, soapy water 4 x daily
• Collection of pus: drained directly
• Pus reached subungually: Portion of the nail removed

Question 17

Treatment of chronic paronychia

Answer 17

• Keep the hand dry with topical and/ or systemic antifungals (Usually fungal)
• If retained piece of nail acts as foreing body - treatment is surgical

Question 18

Symptoms of distal pulp infection

Answer 18

• Prickly pain and tightness in the pulp
• Becomes severe, bursting, throbbing feeling which keeps the patient awake at night
• Progression occurs within 48 hours of onset
• Patients with thick skin over the pulp, only sign may be local tenderness

Question 19

What are the consequences of a missed diagnosis of distal pulp infection ?

Answer 19

• Involve bone of terminal phalanx
• Spread in anterior direction forming a collar stud abcess
• Bursting through skin

Question 20

Clinically, what suggests involvement of the bone in a distal pulp infection?

Answer 20

• Spontaneous sinus formation
• Inadequate incisions resulting in loculation and persistent drainage of pus
• At surgery, feeling bone denuded of periosteum or finding dense, adherent slough in pulp abcess which extends down to the bone

Question 21

What is the cardinal sign for web space infection

Answer 21

splaying of the fingers

Question 22

Where can the infection spread from to cause a web space infection

Answer 22

• side of the fingers
• Dorsum of the hand
• infected callouses

Question 23

What are complications of tendon sheath infections

Answer 23

• Dense adhesions between the tendons and sheath

- Tendon can become frankly necrotic

Question 24

What are the four classic signs of tendon sheath infections

Answer 24

• Finger is diffusely swollen
• Finger held in slightly flexed position
• Passive extension elicits severe pain
• Tenderness along whole course of flexor sheath

Question 25

Tendon sheath infections of the thumb and little finger can spread to where?

Answer 25

Thumb: Volar aspect of forearm

Little finger: Radial and ulna bursae

Question 26

What is the cardinal sign for deep palmar space infection

Answer 26

Filling of the normal cup of the palm

Question 27

What are the two forms of human bites seen

Answer 27

• Direct bite of the hand with or without loss of tissue and/ or digital amputations
• Punch injury

Question 28

What antibiotic regimens should be given to human bites of the hand

Answer 28

• Oral: amoxicillin, clavulanic acid and metronidazole

- IV: penicillin, Gentamycin and metronidazole