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Outline
Pathology Clinical features Principle of treatment Diseases :
(i) Paronychia (ii) Felon (iii) Suppurative tenosynovitis (iv) Deep fascial space infection (v) Septic Arthritis (vi) Bites (vii) Mycobacterial infection (viii) Fungal infection
Pathology
Causing oedema, suppuration and increased tissue tension
Infection
In closed compartment, high pressure may threaten blood supply tissue necrosis
Clinical Features
Usually there is history of trauma (superficial abrasion, laceration or penetrating wound) Few hours or days later, fingers / hands become painful (throbbing) Ill and feverish Predisposing conditions (DM, IVDU and immunosuppression)
Local Examination
Redness of the skin Swelling Local tenderness Superficial infection able to flex infected finger Deep infection unable to flex the infected finger Lymph node (Swollen, Lymphagitis) General examination look for sign of septicemia
Investigation
X Ray - Unhelpful in early stages of infection
- Few weeks later (may show features of osteomyelitis, septic arthritis or bone necrosis)
Septic Arthritis
Osteomyelitis
Principles of Treatment
4 principles : Antibiotics
Rest, Splintage and elevation Drainage Rehabilitation
Antibiotics
Starts immediately after the clinical diagnosis is made Flucloxacillin or cephalosporin If suspect bone infection add fucidic acid For bites give broad spectrum penicillin Change antibiotic when bacterial sensitivity is known
Drainage
Signs of abscess drainage culture End of operation hand is splinted in the position of safe immobilization A sling is used to keep the arm elevated
Hand Infections
Paronychia Felon Suppurative Tenosynovitis Deep Fascial Space Infection Septic Arthritis Bites Mycobacterial Infections Fungal infections
Commonest Seen most in children or in older people after rough nailtrimming Clinical features:
Edge of nail fold red, swollen and tender Abscess may form in the nail fold If left untreated, pus can spread under the nail
Treatment:
At first sign of infection, antibiotics may be effective. If pus present, it must be released by an incision.
If pus has spread under the nail, part or all of the nail may need to be removed.
Chronic paronychia
May be due to:
Inadequate drainage of an acute infection A fungal infection which require specific treatment
Topical or oral antifungal used to eradicate infection If fail with antifungal, nail bed may have to be laid open - marsupialized
Treatment:
If recognized early, antibiotic and elevation of hand is sufficient. If abscess formed, pus is released by small incision over the site of maximum tenderness. If treatment delayed, infection may spread to bone, joint or flexor tendon sheath. Post-operatively, finger is dressed and antibiotic is modified and continued.
Herpetic Whitlow
Clinical features:
Small vesicles Coalesce and ulcerate.
Subsides after 10 days and may recur. Treatment aciclovir at early stage.
Tendon sheath is a closed compartment extending from the distal palmar crease to the DIP joint.
Consequences:
Delayed diagnosis vascular occlusion and tendon necrosis Neglected infection, may spread proximally to:
ulnar and radial bursa horse shoe abscess Flexor compartment at wrist and Paronas space in forearm median nerve compression
Treatment:
Hand is elevated, splinted and antibiotics are administered IV. No improvement after 24 hours, surgical drainage is essential. Post-operatively, hand is swathed in absorbent dressing and splinted in the position of safe immobilization. Hand therapy if there is stiffness.
4 potential spaces
Thenar space Midpalmar space Dorsal subaponeurotic space Subfacial web space
Infection from
Direct penetrating trauma Contiguous spread Hematogenous spread
Midpalmar infection
Loss of normal hand concavity Tenderness of central palm Pain with movement of 3rd and 4th digits Can be from tenosynovitis of digits 3,4,5
Septic Arthritis
Organism Staphylococcus aureus, Streptococcus, Haemophilus influenza. Common cause of MCP infection is fight-bite.
Clinical features:
Pain, swelling and redness of single joint Restricted movement
Treatment:
IV antibiotics are administered and hand is splinted. Inflammation persist after 24 hours or there is sign of pus, open drainage is needed.
Post-operatively, copious dressing is applied and hand is splinted in the position of safety for 48 hours then movement is encouraged. IV antibiotics are continued until all signs of sepsis have disappeared.
BITES
Animal Bites Human Bites
Animal bites:
Usually inflicted by cats, dogs, farm animals and rodents. May become infected. Organisms staphylococcus, streptococci, Pasteurella multocida.
Human bites:
More prone to infection.
Fist fight consist only the dorsal wound over the one of MCP knuckles.
Investigation:
Xray Swab for c+s
Treatment:
Fresh wounds
Debridement. Hand is splinted and elevated. Antibiotics given as a prophylaxis.
Infected wounds
Debridement and wash-outs. IV antibiotics broad spectrum penicillins.
Post-operatively
Copious wound dressings. Splintage in safe position. Encourage movement once infection resolved
Mycobacterial Infections
Fishmongers infection
Chronic infection caused by Mycobacterium marinum.
Organism is introduced by prick injuries from fish spines or hard fins. May appear as a superficial granuloma. Deep infection can give rise to an intractable synovitis of tendon or joint. Diagnosis require biopsy. Treatment:
Superficial lesions heal on their own or otherwise need to be excised. Deep lesions require surgical synovectomy. Prolonged antibiotic to prevent recurrence. Reommended broad spectrum tetracycline. Or else chemotherapy with ethambutol and rifampicin.
Tuberculous tenosynovitis
Uncommon. Diagnosis should be considered in patients with chronic synovitis once has excluded rheumatoid diseases. Confirmed by synovial biopsy. Treatment: synovectomy and prolonged chemotherapy
Fungal infections
Tinea of nail
Difficult to eradicate Require oral antifungal and complete removal of nail
Subcutaneous infection
Usually caused by thorn prick Chronic ulceration at the prick site Unresponsive to antibiotic Confirmed by microbacterial culture Treatment: oral potassium iodide
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