1. Soft Tissue Hand Infections
"In almost all cases of serious infection the difficulty is to make a correct diagnosis both as to the nature of the infection and the position of the pus.” – Kanavel, Infections of the Hand, 1939

2. Epidemiology ~35% of admissions Young adults/immunocompromised
Pre-abx were a major contributor to permanent disability
Many require surgery  timing affects outcomes

3. Principles
Diagnosis - ?Drainage/debridement - antibiotics – hand therapy
Role of antibiotics (not for deep palmar space infections)
Empirical use  targeted
Early diagnosis without collection (24-48 hrs)
High dose/splint/elevate
Monitor
Surgery
Release pus/decompression
Consider placement of incisions
Usually leave open
Splinting vs early ROM

4. Paronychia/Felon/Whitlow

5. Paronychia Infection of soft tissue folds around nail
Nail biting/manicures/ingrown  colonizations
Acute vs Chronic (prolonged exposure to water, superinfection with fungus, fibrosis)
Paronychia  eponychia ‘runaround’  abscess
Surgical management  drainage
Avoid nail bed
If bed involved, elevated and remove overlying plate

6. Felon Distal pulp space – fibrous septa Staph aureus/grm +ve’s
Abscess  necrosis
Staph aureus/grm +ve’s
Usually acute presentation
Surgery – abscess or evidence of increased pressure
Antibiotics: penicillin/1st gen ceph + gram –ve coverage in immunocompromised
Complications:
Osteomyelitis/Flexor tenosynotivitis/septic arthritis/paronychia
Amputation

7. Surgical approach
Aims – clear infection/relieve pressure/prevent NV compromise
Range of approaches:
Avoid sheath
Consider scar
Post Op
Leave open
Splint 48 hrs / soaks / ROM

8. Herpetic Whitlow Contact inoculation with HSV
Dentists/health care workers/children
Tingling /burning  vesicles  blisters / pustules
Rx: cover blisters. Self-limited (~ 21 days).
Acyclovir for severe infections/immunocompromise d

9. Finger Tip Infections Paronychia Felon Herpetic Whitlow Nail fold Pulp
Either
Pain/abscess/cellulitis
Severe throbbing pain Dependent
Tense
Tingling/vesicles
Soft pulp space
Trauma
-- staph /anaerobes
Penetrating trauma
-- staph
HSV - contact

10. Flexor Tenosynovitis Flexor sheaths
Closed spaces (A1  A5)
LF  UB, Thumb  RB
RB and UB  Space of Parona
(between FDP and PQ)
Infections/adhesions  loss of gliding mechanism
Loss blood supply  necrosis

11. Flexor Tenosynovitis
Inoculated by penetrating trauma or spread of infection
Staph/strep vs pasteurella/eikenella
Clinical: Kanavel’s Signs (not specific)
Role for non-operative treatment if caught early

12. Infections of Bursa Spread of flexor tenosynovitis through sheaths
FPL (thumb)  Radial Bursa
FDP (little)  Ulnar Bursa
Proximal incision  can cut down onto probe

13. Surgical approach Michon Stage Findings Treatment Stage I
Increased fluid in sheath, mainly a serous exudate
Catheter irrigation
Stage II
Purulent fluid, granulomatous synovium
Continuous indwelling catheter irrigation
Stage III
Necrosis of the tendon, pulleys, or tendon sheath
Extensive open debridement and possible amputation
Drainage of sheath/debridement of necrotic tissue
Open: decompress entire sheath with mid-axial and palmar incisions
Closed: palmar incision proximal to A1, mid-axial distal to A4

14. Flexor Tenosynovitis
No definitive evidence for closed versus open in terms of outcome (Gutowski. Ann Plast Surg. 2002;49:350–354)
No clear role for continuous catheter irrigation (Lille, J Hand Surg Br Jun;25(3):304-7)
Irrigation with local anaesthetic can help with post-op analgesia (Gaston, Tech Hand Up Extrem Surg. 2009)
Prognostic Factors (Pang, J Bone J Surg, Am, 2007)
Age > 43 years, Co-existent illnesses, Subcutaneous purulence, Digital Ischaemia, Polymicrobial infection
Seems to be a trend towards closed approach and intra- operative irrigation +/- return to OT as indicated

15. Palmar Space Infections
Subfascial palmar space
Dorsal sub-aponeurotic
Thenar
Mid palmar

16. Subfascial Palmar Space
Communicates with the dorsal subcutaneous space via web-spaces  spread dorsally
“Collar button abscess”
Relationship between skin and fascia limits proximal spread
Causes: fissures/extension from prox phalanx/callus
Findings: severe distal palmar swelling and abducted digit

17. Treatment Volar and dorsal incisions Leave open, may need re-look
Palmar: zig-zag between edge of web and distal palmar crease
Dorsal: ~2cm longitudinal incision in the distal web space
Leave open, may need re-look

18. Dorsal Subaponeurotic Space Infections
Beneath extensor tendons
Causes: penetrating trauma/IVDU/bites
Swelling/erythema/tenderness +/- collection
Drainage via longitudinal incision over 2nd and 4th MCs
Leave coverage over tendons to prevent dessication

19. Thenar Space Infection
Space following adductor pollicus
Dorsal: AP, Volar: index and 1st lumbrical, Radial: insertion of AP, Ulnar: oblique septum (skin to 3rd MC)
Causes: injury/abscesses/tenosynovitis/extension for RB or midpalmar space
Clinical
Swelling of thenar eminence / 1st webspace / thumb abducted
Pain on adduction or opposition
Surgery  drainage via volar and dorsal incisions

20. Midpalmar Space
Dorsal: intrinsics, Volar: flexors, Radial: Oblique septum, Ulnar: hypothenar muscles, Distal: septa of palmar fascia: Proximal: fascia at CT
Clinical
Swelling, volar tenderness, loss of palmar concavitiy, MD and RF flexed
Wide palmar incisions +/- resection of palmar fascia

21. Approaches to the mid palmar and thenar spaces

22. Fight Bites
Treat laceration over MC head as a human bite until proven otherwise
Clenched fist: inoculation of tissue and joint Assume polymicrobial infection (staph/strep/eikenella)
Goals: treat early, appropriate antibiotics, usually facilitate exploration in OT explore and washout joint

23. Summary Soft tissue infections of the hand are common
Prompt diagnosis and treatment directly effects outcomes
Certain early onset infections may have a trial of non-operative management
Surgery for Deep palmar space infections
Must consider early ROM and therapy to combat long-term stiffness