Epidemiology:

- Hand infections are common, accounting 35% of patients admitted to hand surgery services.

Generally

- Majority of hand infections occur following neglected minor trauma.

hand infection

Cellulitis
- Definition:
o Cellulitis is a nonsuppurative bacterial infection of the skin and subcutaneous tissue
- Virtually all hand infections begin as cellulitis.
- Cellulitis is a superficial process that presents with pain, swelling, and erythema and associated
with fever, malaise, and leucocytosis..
- It is usually associated with previous skin trauma or ulceration
- Most common causative agent is staph. Aureus.
- Predisposing factors
o DM
o Older aged
o Itch
o Immunodeficiency
o Dry skin
o Eczema
- DDx:
o Lyme disease
- Treated by antibiotics
- Complication:
o Rarely cause Necrotizing fasciitis
Acute Paronychia
- A paronychia is an infection of the soft tissues surrounding the fingernail.
- It is the most common infection of the hand.
- More common in female (female/male ration = 3:1)
- It occur as result of inoculation of bacteria between nail and surrounding tissue.
- This occur after nail biting, inappropriate nail trimming, poor manicuring, or a small puncture
wound.
- Causative organism:
o Staph. Aureus (the most common)
o Anaerobes (usually through contamination of wound by oral secrtion)
- Hx
o History of minor trauma
 o Celullitis (usually in lateral nail fold)
- Physical examination
o Localized pain
o Swelling around nail
- DDx
o Kaposi sarcoma
o Melanoma
o squamous cell carcinoma
o mucous cyst
o pyogenic granuloma
- investigation:
o aerobic and anaerobic cultures
o X-ray (to see trauma, foreign body, and to rule out osteomyelitis)
- Complication:
o Abscess formation
o eponychia
o Felon
o Osteomylitis
o Flexor tenosynovitis
- Treatment
o If early diagnosed before abscess formation, Conservative treatment (oral antibiotics)
o If there is localized abscess, we will do separation without incision but may with partial
nail removal
 Instrument needed:
 Freer elevator
 an 18 gauge needle or blade no.11
 The goal:
 separate the cuticle of the lateral nail fold to drain the pus.
 So the blunt separation done proximally to open the eponychial cul – de –sac.
 We will use The Freer elevator or straight hemostat to elevate portion of nail
adjacent to paronychia
 one fourth of nail is cut with scissors in order to decompress the paronychium
and facilitate drainage.
 To ensure drainage we can package tiny wick.
 A small portion of gauze is placed under the elevated nail fold, and sink
hydrotherapy is begun in 48 hours.
o If there is deep abscess, there is no drainage after partial nail removal, so we need to do
more aggressive approach by separated incision with blade no.11 in the nail fold.
o When the infection extended proximally to involve entire eponychium, it will called
eponchia.
  We will need to remove proximal one third of the nail to drain proximal pus.
 a non – adherent gauze dressing is required to prevent premature closure of the
cavity.
 If eponchia left untreated, nail deformity can result from pressure of confined
collection of pus on the germinal matrix.

Chronic paronchia
- it is cause by fungal infection (usually by Candida).
- it doesn’t related to acute paronchia
- Risk factor:
o DM
o workers whose jobs constantly expose their hands to water or chemical solvents, such
as:
 dentistry
 nursing,
 dish-washing.
- The chronic paronychia is most commonly seen with the "ingrown toenail"
- It result in thickening and purulence of the eponychial fold and loss of the cuticle.
- Diagnosed through of scrapings and fungal cultures.
- Managed by keeping hand dry and using antifungal creams.

 Acute paronchia is more painful than chronic paronchia

 Painful paronychiaa may be indicative of acrokeratosis paraneoplastica, which is associated with
squamous cell carcinoma of the larynx.

Felon (pulp space)

- Definition:
o A felon is a subcutaneous abscess in a closed – space of the pulp of a finger or thumb.
- So Pus trapped between the specialised fingertip septae causes intense fingertip pain, and may lead to terminal
phalangeal bone infection, erosion and sequestrum formation.
- thumb and index finger are the most commonly affected digits.
- Causative organism:
o Usually Staphylococcus aureus
o S. pyogenes
o Gram –ve in immunocomprised patient
- Hx
o Hx of puncture wound
o Hx of paronchia
o Swelling and throbbing pain of pulp (due to presence of abscess in close compartments.
 The pain is worsened by dependency, and may keep the patient from sleeping
at night.
- Physical examination:
o Edematous, erythematous, and tender pulp.
o Reactive lymphadenopathy behind the elbow and in armpit.
o Fever
o Fluctuance (a soft, boggy feel on palpation)
- DDx
o herpetic whitlow
o pyogenic flexor tenosynvitis
- complication
o pulp necrosis
o osteomyelitis
o septic arthritis
o pyogenic flexor tenosynovitis
- management
o early when cellulitis just start, can treated by antibiotics.
o Usually abscess already formed and that will need surgical drainage.
- Surgical treatment of felon
o Many incisions described , you should choice one that with:
1- Minimal risk of iatrogenic injury to neurovascular structures
2- leave an acceptable scar
3- avoid the flexor tendon sheath
4- drain all fluid collections adequately
o what are the types of incision have for felon?
1- Longitudinal volar incision
2- Unilateral longitudinal incision
3- Bilateral longitudinal incision
- Why all incision longitudinal, no Transverse one?
o Because Transverse skin incision may injure neurovascular bundle and so cause ischemia
or anesthesia.
- Longitudinal volar incision
o Preferred when the abscess is pointing.
o We will use blade no. 11
o The incision should not cross the DIP joint flexion crease to prevent flexion contracture
and avoid extension of infection into flexor sheath.
- Unilateral longitudinal incision
o preferred when here is no most fluctuation point or a draining sinus.
o The incision will be on lateral aspect of the midlateral line , 0.5 cm. distal to the DIP joint
flexion crease and not go to the fingertip.
o The blunt instrument is used to separate the fibrous septa from the periosteum of the
phalanx.
 o the lateral skin incision should be performed on the ulnar side of index, middle
and ring finger, but on the radial side of the thumb and small finger.
-  Bilateral longitudinal incision
o Rarely needed
o Indicated in severe infection where unilateral incision not drain adequately.

Herpetic whitlow

- Definition :infection of the distal finger typically results from direct inoculation of the herpes
simplex virus into broken skin.
- Causative agent:
o HSV type 1 , HSV type 2
- Misdiagnose as bacterial paronychia or felon.
- HX
o Hx of Genital herpes or gingivostomatitis in children
o Burning Pain for 24-48 before skin change follow by erythma and swelling, then
formation of clear vesicle.
o Usually affect only one finger
o The pulp of the affected digit is not tense as in a felon.
- Physical examination
o edema, erythema, tenderness of affected digit
o Small clear or turbid vesicles with or without hemorrhage may be seen, These vesicles
may be ruptured and become encrusted, mimic pyogenic paronychia or a felon.
o no purulent discharge except in secondary bacterial infection
- Investigation
o viral culture
o Tzanck smear (demonstrates the presence of multinucleated giant cells)
- Ttt
o Self resolve after 3-4 weeks, we can give anti-inflammatory agents and apply a dry
gauze dressing to the affected finger to prevent further spread of the lesion.
oIn immunocomprised patient, Acyclovir used to prevent viremia.
oincision and drainage of herpetic whitlow is generally contraindicated, it worsen the
outcome by causing viremia. (so distinguish it from paronchia and felon is important)
- Prognosis
o 20-50% of cases will get recurrent infection that less severe than primary one.

Pyogenic Flexor Tenosynovitis

- Definition :
 o Pyogenic flexor tenosynovitis is a closed – space infection in the flexor tendon sheath of
the digit
- It is the most serious hand infections encountered.
- The ring, middle, and index fingers are most commonly affected
- Causative agent
o S. aureus (the most common causative)
o Other Staphylococcus and Streptococcus species.
o Gonococcus (through hematognous spread)
- Hx
o Hx of penetrating trauma or bacteriemia
o Hx of complicated felon.
- Physical examination
o Kanavel cardinal signs of flexor tenosynovitis:
 (a) fusiform swelling of the finger
 (b) partially flexed posture of the digit
 (c) tenderness over the entire flexor tendon sheath
 (d) disproportionate pain on passive extension This sign is the most
constant and typically the first present in early cases.
o These sing’s may incomplete or absent in early stages, under antibiotics, and in
immnocomprised patient.
- DDx
o phalangenal fracture
o arthritis
o Gout
o inflammatory flexor tenosynovitis.
- Complication
o destruction of the gliding surfaces in the sheath
o necrosis of tendons
o Osteomyelitis
o septic arthritis
o horseshoe abscess from communication with Parona’s space of the wrist
o thenar space abscess from rupture of pyogenic flexor tenosynovitis of index finger
o midpalmar space abscess from rupture of pyogenic flexor tenosynovitis of middle and
ring fingers
o stiffness (due to adhesions between the tendon and its sheath)
o amputation
- Investigation
o aerobic and anaerobic cultures.
o X-ray to rule out phalangeal fracture, bony involvement and foreign body.
- Ttt
o Early diagnosed (within 24-48 h) treated by antibiotics.
 o Late diagnosed cases need surgical treatment
- Surgical treatment
o Closed irrigation
 For less severe cases (no necrosis of flexor tendon, pulleys or sheath)
 We will do two incision one proximal, other distal.
 Proximal incision will be transverse, vertical or zigzag made over the A1 pulley of
the finger or over the thenar crease of the thumb.
 So we will drain the pus and visualize the tendon and sheath for necrosis (no
necrosis continuo as close irrigation method)
 Then we will do distal incision which made over the region of A5 pulley.
 For distal incision, a midaxial incision is preferred and made on the ulnar side of
index, middle and ring finger ; in the thumb and small finger, the radial side is
preferred.
 Then we will put a 16 – gauge polyethylene catheter or # 3.5 – 5 French feeding
tube is inserted under the A1 pulley for a distance of 2 cm and the tendon
sheath is irrigated by sterile normal saline until the fluid is clear.
 Suture incisions and leave small drain distally for outflow.
o Open drainage and debridement
 When there is necrosis
 The same things two incisions but here zigzags contraindicated (because
necrosis will complicate closure) .

Palmar space infections

- Hand contain five potential spaces located deep inside the hand:
o thenar space
o midpalmar space
o hypothenar space
o interdigital web space
o dorsal subaponeurotic space.
- Clinically the most important spaces are the thenar and midpalmar spaces.
- Causative organism:
o S.aureus (the most common)
o streptococcus species
- rout of infection
o through penetrating trauma
o complicated pyogenic flexor tenosynovitis
o hematogenous spread
- thenar space infection
o physical examination
 marked swelling of thumb-index web space
  grossly swollen of thenar eminence
 flexed and abducted resting posture of the thumb
 pain with passive adduction
o Surgical treatment
 drainage and debridement performed at greatest tender area curved incision in
the web between the thumb and index finger.
 The incision can be done on the thenar eminence, parallel to the thenar crease.
Great care is taken to avoid injuring the palmar cutaneous branch of the median
nerve in the proximal subcutaneous portion of the incision, and the motor
branch of the median nerve, which is located at the point where a flexed middle
finger touches the palm.
 If it is necessary, combined dorsal and volar approach can be performed.
 Closed irrigation technique can be performed.
- Midpalmar space infection
o Physical examination:

 pain and swelling in the central palm

 loss of palmar concavity

 swelling of the hand

 limitation and pain with movement of the middle and ring fingers
o surgical treatment
 drainage through a transverse incision in the middle third of the palmar crease
or wherever fluctuation is maximal.
 Another skin incision can be made along the ulnar border of the hand
between the fifth metacarpal and the hypothenar muscle.
 Closed irrigation technique can be performed.
- Hypothenar space infection
o Physical examination

 pain , swelling and tenderness at hypothenar eminence.

o Surgical treatment
 Drainage through a vertical or curved incision can be performed over the
hypothenar.

- Interdigital web space infection

o Physical examination

 pain and swelling localized to the web space.

 The point of maximum tenderness is on the palmar surface of the web.

  If infection is severe, the fingers on either side of the web separate from each
other

o The infection may spread

 1.     posteriorly towards the dorsum caused double – abscess configuration.

 (2) along a lumbrical canal into the midpalmar space.

 (3) across the finger into an adjacent web space.

 (4) distally into the finger.

o Surgical treatment
 Surgical incisions are usually performed both on the dorsal and palmar
aspect of the infected web space.
 A curved or zigzag incision is made on the palmar surface
 A longitudinal incision is made between the base of finger on the dorsal
side.
 Blunt dissection is used to establish the communication between the two
incisions and protect the digital nerves and arteries.
 The superficial transverse metacarpal ligament and other fibers may be
divided to allow better exposure.
 Closed irrigation technique may be used.
- Dorsal subaponeurotic space infection
o Physical examination

 pain and swelling at the dorsum of hand

 limitation of finger extension.

 The clinical manifestation often is similar to cellulitis or a simple subcutaneous

abscess.

 The swelling on the dorsal aspect of the hand may be mistaken from infection in
the midpalmar space, but the dorsum will not be tender, fluctuant or
erythematous in the midpalmar infection.

o Surgical treatment 
 Drainage is performed by a longitudinal incision at the point of the greatest
tenderness.
- Note
o When draining any closed space infection, you should be aware of the possibility of a
collar button abscess( collar stud abscess) which occurs when an abscess spreads
between distinct tissue layers through a small sinus tract, leading to an hourglass
configuration. So don’t drain superficial component only.
o On drainage try best to avoid iatrogenic injury to important neurovascular structures.