Townsend: Sabiston Textbook of Surgery, 18th ed.

Copyright 2007 Saunders, An mprint of Elsevier

NFECTONS
Hand infections commonly present to the surgical resident covering the emergency room. When
diagnosed and treated properly initially, most patients do well. The extent of deep palmar infections
may often be underestimated during the early phases because the volar aspect of the hand does not
show edema as readily as the dorsal aspect of the hand. Hand infections can result in significant
morbidity and severe functional compromise if not appropriately diagnosed and treated. Some of the
more common types of infections are discussed next.
SuperficiaI ParonychiaI Infections
Paronychia is the most common infection of the hand and usually results from trauma to the
eponychial or paronychial region. The infection localizes around the nail base, advances around the
nail fold, and burrows beneath the base of the nail. f pus is trapped beneath the nail, pressure on the
nail evokes exquisite pain. The most common causative organism is Staphylococcus aureus.
Treatment for early cases is with antibiotics, preferably penicillin in combination with a -lactamase
inhibitor such as sulbactam or clavulanic acid. After an abscess develops, surgical drainage is
required. The surgical approach to an acute paronychia depends on the extent of the infection.
ncisions may not be necessary. A Freer elevator is used to lift about one fourth of the nail adjacent
to the infected perionychium, extending proximally to the edge of the nail. This portion of the nail is
transected and gauze packing inserted beneath the nail fold. A single incision to drain the affected
perionychium also allows elevation of the eponychial fold when both eponychium and paronychium
are involved [46] [47] [48] ( Fig. 74-31 ).
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Infections of the Intermediate-Depth Spaces
nfections of the intermediate-depth spaces are pulp space infections (felons) and also deep
webspace infections. The former may involve the terminal pulp or middle or proximal volar pulp
spaces and may result from direct implantation with a penetrating injury or may represent spread
from a more superficial subcutaneous infection. The volar pulp of the distal digital segment is a
fascial space closed proximally by a septum joining the distal flexion crease to the periosteum, where
the long flexor tendon is inserted. This space is also partitioned by fibrous septa. Tension in the distal
digital segment can become so great that the arteries to the bone are compressed, resulting in
gangrene of the fingertip and necrosis of the distal three fourths of the terminal phalanx. With
infection of the digital pulp space, one must not wait for fluctuance before making the decision for
surgery because of the danger of ischemic necrosis of the skin and bone. Clinical diagnosis is made
by rapid onset of throbbing pain, swelling, and exquisite tenderness of the affected pulp space.
Surgical drainage is required. Either a single volar longitudinal incision or a unilateral longitudinal
incision may be used (see Fig. 74-31 ). Postoperative care includes packing of the wound and
elevation of the extremity. Use of antibiotics is guided by the Gram stain. Similar to a paronychia, S.
aureus is the most common etiologic agent. Spread from a pulp space infection may move into a joint
space or the underlying bone, or burst through the septum proximally to involve the rest of the finger.
More proximally, a pulp space infection at the base of the finger can travel through the lumbrical
canal into the palm to create a deep palmar space infection. [24]
Webspace abscesses result from either direct implantation or spread from a pulp space. An inflamed
and tender mass in the webspace separates the fingers. There is loss of the normal palmar concavity
with a widened space between the fingers. Dorsal swelling is present and must not be mistaken for
the infection site. A surgical incision is placed transversely across the webspace, and a counter
longitudinal incision may be placed dorsally between the bases of the proximal phalanges; a
generous communication is established between these two incisions ( Fig. 74-32 ).
Figure 74-31 ncisions for paronychia (A) and felon (B).
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Deep Infections
Deep Palmar Space nfections
These infections are localized to the deep space of the hand between the metacarpals and the
palmar aponeurosis. A transverse septum to the metacarpal of the middle finger divides the deep
space into an ulnar midpalmar space and the radial thenar space. The transverse head of the
adductor pollicis partitions the thenar space from the retroadductor space. There may be ballooning
of the palm, thenar eminence, or posterior aspect of the first webspace depending on which of the
affected spaces is involved with an abscess. The dorsal subaponeurotic space of the hand deep to
the extensor tendons may also be affected by an isolated infection, generally as the result of direct
implantation ( Fig. 74-33A ). For a thenar space infection, the preferred approach to surgical drainage
is a dual volar and dorsal incision (see Fig. 74-33B ). On the volar side, an incision is made adjacent
and parallel to the thenar crease. Great care is taken to avoid injury to the palmar cutaneous branch
of the median nerve in the proximal part of the incision and the motor branch of the median nerve in
Figure 74-32 ncisions for webspace abscess between the little and ring fingers.
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a deeper plane. A second, slightly curved, longitudinal incision is made on the dorsum of the first
webspace. Dissection is continued more deeply into this area between the first dorsal interosseous
muscle and the adductor pollicis. A drain is placed in the incision after thorough exploration of the
respective spaces. With midpalmar space infections, dorsal swelling of the hand will be present (as is
the case with all palmar infections) and must not be mistaken for the infection site. Motion of the
middle and ring fingers is limited and painful. A longitudinal curvilinear incision is the preferred
approach for drainage of this space (see Fig. 74-33B ).
nfection of Parona's space occurs in the potential space deep to the flexor tendons in the distal
forearm and superficial to the pronator quadratus muscle. t is usually the result of spread from the
adjacent contiguous midpalmar space or from the radial or ulnar bursa. Swelling, tenderness, and
fluctuation will be present in the distal volar forearm. A midpalmar infection may be associated.
Active digital flexion is painful, as is passive finger extension. A surgical incision must be planned so
as to leave the median nerve adequately covered with soft tissue.
Pyogenic Flexor Tenosynovitis
Figure 74-33 A, Deep spaces of the hand and synovial bursae. nfections may be bound by these spaces or may track along
anatomic dissection planes between these spaces. B, ncision for thenar space infection. A dorsal first webspace incision is also
often required. ncision for midpalmar space abscess.
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Kanavel's cardinal signs include the following characteristics: the finger is held flexed because this
position allows the synovial sheath its maximum volume and eases pain; symmetrical fusiform
swelling of the entire finger is present with edema of the back of the hand; the slightest attempt at
passive extension of the affected digit produces exquisite pain; and the site of maximum tenderness
is at the proximal cul-de-sac of the index, middle, and ring finger synovial sheaths in the distal palm
or in the case of infection of the sheaths of the thumb and little finger more proximally in the palm
(see Fig. 74-33 ). The radial and ulnar bursae communicate in about 80% of cases and may be
simultaneously infected. Bursal infections may spread into the forearm space of Parona, deep to the
flexor tendons in the distal part of the forearm, creating a horseshoe abscess.
Pyogenic flexor tenosynovitis may be aborted with parenteral antibiotics, extremity elevation, and
hand immobilization if the patient is seen within the first 24 hours of onset of infection. f this course is
unsuccessful, or if the patient is seen more than 48 hours after onset of infection, surgical drainage is
undertaken. The preferred surgical approach is through two separate incisions, with the first being a
midaxial incision made on the finger, usually on the ulnar side of the digit (on the radial side of the
thumb or little finger); the digital artery and nerve remain in the volar flap with the dissection
proceeding directly to the tendon sheath. Synovium between A3 and A4 pulleys is incised, and
cloudy fluid is encountered. A second incision is made in the palm over the tendon to drain the cul-
de-sac. A 16-gauge polyethylene catheter is inserted beneath the A1 pulley into the sheath, and the
sheath is flushed manually with sterile saline every 2 hours after surgery; a bulky hand dressing
absorbs the drainage. Recent studies have found that postoperative catheter drainage may not
always be necessary. [50] [51]
Chronic and AtypicaI Infections
Chronic paronychia are generally the result of Candida albicans (>95%) infection and are not
bacterial. When bacteria are involved, they are more commonly atypical mycobacteria or gram-
negative organisms. These chronic paronychia generally respond to treatment with topical antifungal
agents, although oral antifungal agents are sometimes used. Occasionally, surgical treatment by
means of marsupialization of the eponychial fold is required. f the lesion is refractory to treatment,
the possibility of a malignancy is entertained.
Chronic tenosynovitis can occur either in the flexor tendons or in the dorsum of wrist and extensor
tendons. t is usually of a granulomatous type and is caused by mycobacteria or fungi. Treatment
includes surgical excision of the involved synovium as well as prolonged treatment with the
appropriate antimicrobial agents. Chronic infected tenosynovitis must be differentiated from other
causes of chronic granulomatous synovitis, such as sarcoidosis, amyloidosis, gout, and rheumatoid
arthritis.
Herpetic "WhitIow"
Herpetic Whitlow is caused by type or herpes simplex virus and may be confused with a
paronychia. nfection begins with the appearance of small clear vesicles with localized swelling,
erythema, and intense pain. The vesicles may subsequently appear turbid and coalesce over the
next few days before ulcerating. Diagnosis is confirmed by culturing the virus from the vesicular fluid,
assessing immunofluorescent serum antibody titers, or performing a Tzanck smear. However, these
measures are rarely required because clinical diagnosis is usually sufficient. nfection can occur from
either autoinoculation from an oral or genital lesion or exposure as a health care worker. Pain is often
out of proportion to physical findings. Treatment is generally nonoperative because this infection is
usually self-limited. Antivirals such as acyclovir or famciclovir may be of some benefit if started within
the first 48 hours of symptom onset. Surgical incision and drainage can lead to systemic involvement
and possible viral encephalitis.
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AnimaI and Human Bites
The most striking difference in the microbial flora of human and animal bite wounds is the higher
number of bacterial isolates per wound in human bites, the difference being mostly due to the
presence of anaerobic bacteria. Human bites can occasionally transmit other infectious diseases
such as hepatitis B, tuberculosis, syphilis, or actinomycosis. The incidence of Eikenella corrodens in
human bite infections of the hand has been reported to vary between 7% and 29%. Most commonly
isolated organisms from infected human bite wounds are, as in animal bites, d-hemolytic
streptococcus and S. aureus, -lactamase-producing strains of S. aureus, and Bacteroides species.
Anaerobic bacteria are more prevalent in human bite infections than previously recognized, including
Bacteroides, Clostridium, Peptococcus, and Veillonella. Most studies of animal bite wounds are
focused on the isolation of Pasteurella multocida, disregarding the role of anaerobes. Recent studies
show that dog bite wounds point toward multiple organisms, with P. multocida being isolated from
only 26% of dog bite wounds in adults. Most animal bites cause mixed infections of both aerobic and
anaerobic bacteria.
Pyogenic joint infections usually result from trauma, such as a bite wound from a tooth when the
assailant's hand impacts the jaw. A tooth impacting the clenched fist of an attacker penetrates the
skin, tendon, joint capsule, and metacarpal head. Once the finger is extended, the four puncture
wounds separate from each other to create a closed space within the joint. All such so-called fight
bite wounds of the MP joint need to be explored surgically, dbrided, and thoroughly lavaged. Human
bite wounds are not closed primarily and are treated with appropriate antibiotics.
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