Hand Infections

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Hand Infections
Doug Hanel M.D. Department Of Orthopaedics
Harborview Medical Center Childrens Hospital
Regional Medical CenterUniversity Of Washington

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Hand Infection

• Frequently Injured, Infrequently Infected
• Abundant Blood Supply
• Potential Problems gtgtConfined Spaces -
  Joints - Tendon Sheaths - Compartments and
  Bursae

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Hand Infection Cellulitis

• Redness, Swelling, Pain
• Early 24- 48H
• Rx - I.V. antibiotics - Splinting - Elevation
• No Improvement gtgt I D

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Hand Infection Cellulitis

• S. aureus Cephalosporins, Timentin
• Streptococcus Penicillin, Cephalosporins
• Pasturella Multicida gm- coccus Animal bites
  Penicillin/Cephalosporin
• Eikenella Corodens anaerobic gm - rod Human
  bites Penicillin, Timentin

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Hand Infection Abscess

• Later 24-72 H
• Fitful Sleep
• Fluctuance (lance vs aspirate)
• Does it involve closed spaces?
• I D (under Operating Room control) -
  tourniquet optional
• Where do you cut ?

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Hand Infection Abscess
Where do you cut ? Referral?

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Hand Infection Abscess

• Splint and Elevate
• Warm Soaks - Open Wounds
• Irrigating Catheters / Wicks - Closed Wounds
• Gentle ROM
• Culture Specific Antibiotics

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Hand Infection Paronychia

• Common Infection - Nailfold
• Anatomy Para/eponychium
• Early - Warm Soaks - Paronichial Elevation
• Late - Marsupialization - Partial Nail Removal

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Hand Infection Paronychia

• Early - Warm Soaks - Paronichial Elevation

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Paronychial Drainage
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Hand Infection Paronychia

• Late - Marsupialization - Partial Nail Removal
• Refer These

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Hand Infection Felon

• Closed Space
• Anatomy Pulp Septae
• Early - Warm Soaks - Anti Staph/Strep
• Late - Usually Always Late - Go for the pus!!

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DONT TREAT FELONS LIKE THIS !
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Hand Infection Felon
Incision Go directly to the pus

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Hand Infection Palmar Space Infections
3 Potential Spaces Thenar (Third metacarpal
radially) Midpalm (Third metacarpal
ulnarlyParonas (Space between Carpal Tunnel
contents Pronator Quad

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Palmar Space Infections

• 3 Potential Spaces
• Thenar
• Midpalm
• Paronas

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Hand Infection Palmar Space Infections
Incise, Culture, Irrigate, Antibiotics, Soaks,
ROM, Resting Splint

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Hand Infection Palmar Space Infections

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Hand Infection Collar Button Abscess

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Hand Infection Suppurative Tenosynovitis

• Surgical Emergency? (early conservative Rx)
• Painful Swelling
• How Do You Differentiate From Local Abscess?

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Hand Infection Suppurative Tenosynovitis
Kanavels Signs

• finger in slight flx
• fusiform swelling
• pain with ext.
• tenderness along tendon sheath

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Hand Infection Suppurative Tenosynovitis

• Rx Refer
• I D
• Antibiotics
• Irrigation

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Hand Infection Suppurative Tenosynovitis

• Irrigate 24-36H
• Saline 10cc q 1H
• Splint
• Soaks
• Hand Therapy ROM, Splints

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Hand Infection Suppurative Tenosynovitis
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Hand Infection Slowly Swelling Finger

• 40 y/o Man
• Painless Swelling 4 Mos
• No Hx of Trauma
• Labs X-rays Normal

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Hand Infection Atypical Mycobacteria

• M. marinum prolonged non painful
  swelling marine exposure Dx synovial bx,
  debridement Lowenstein- Jensen at 32 C Rx
  debridement and anti-TB

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Hand Infection Atypical Mycobacteria
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Hand Infection Atypical Mycobacteria

• Others
• M. avium/intracelluaris kansasii garden
  exposure
• M. lepraemurium predilection for cooler
  nerves tissue ie ulnar nerve at elbow

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Hand Infection Fight Bite Arthritis
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Hand Infection Fight Bite Arthritis
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Hand Infection Fight Bite Arthritis

• Rx Refer ID Arthrotomy Antibiotics

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Hand Infection Non Bacterial Finger Infection

• 33 y/o Medicine Resident
• 2 Days Post Performing CPR
• Patient Seizes During Intubation
• Hands Caught In Pts Mouth

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Hand Infection Non Bacterial Finger Infection
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Hand Infection Herpetic Whitlow

• Injury Not Always
• Pain, Erythema, Vesicles
• Most Common Hand Infection In AIDS
• ID For Dx only (Tzanck Stain)
• Rx Pain Meds, ? Valtrex 500mg q12H ?

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Hand Infection Herpetic Whitlow
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Hand Infection That Can Kill Your Patients

• 37 y/o MaleInsulin DependentCellulitis Last
  24hHypotensive Difficulty With Glucose Control

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Hand Infection That Can Kill Your Patients

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Hand Infection Necrotizing Infections

• Necrotizing Fasciitis perforator thrombosisgtgtgt
  necrosis gtgtgt microaerophilic strep gtgtgt
  Meleneys
• Myonecrosis clostridia gm rods Gas
  Gangrene

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Hand Infection Necrotizing Infections

• RX Refer Now Surgical Emergency !

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Hand Infection Necrotizing Infections
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Hand Infection Necrotizing Infections

• RX Surgical Emergency !
• Amputation maybe necessary!

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Hand Infections Summary

• Most common organisms are Gm
• Sleepless night pus under pressure
• Pus should be drained
• The shortest distance to the pus is the best
  (felon, tendon sheath, deep space abscess)

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Hand Infections Summary

• Not everything painful is bacterial.
• Things that grow slowly and painlessly are either
  very bad (mets) or are associated with Tb.
• Even simple infections can kill you.
• Inexpensive antibiotics are usually adequate.

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Hand Infection Cost of Antibiotics Per Day

• Kefzol 1g 23.75 x 3
• Pen G 4MU 36.71 x 6
• Gent 2mg/kg 36.26 x 3
• Timentin 3.1g 33.14 x 4 Plus 75.00 per IV
  Administration

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THANK YOU