for interns

1. SKIN, SOFT TISSUE, AND
HAND INFECTION
FOR INTERNS
HAPPY FRIDAY KNIGHT
21ST SEP 2020

6. SEVERITY
• Mild: lesion < 2 cm2, no osteomyelitis, no lymphatic spreading, no sepsis
• Moderate: one of >> lesion > 2 cm2, osteomyelitis, lymphatic spreading,
sepsis
• Severe: criteria moderate + septic shock

7. ABSCESS: A SWOLLEN AREA WITHIN BODY TISSUE,
CONTAINING AN ACCUMULATION OF PUS
http://www.humanillnesses.com/original/A-As/Abscess.html

8. FOLLICULITIS: INFLAMMATION OF THE HAIR
FOLLICLES
http://www.aocd.org/?page=Folliculitis

9. FURUNCLES: INFECTED HAIR FOLLICLES
WITH FLUCTUATIONhttp://health-pictures.com/infection/furuncle.htm#.VdTTZvmqqko

10. CARBUNCLE: MULTIPLE FURUNCLES
http://byebyedoctor.com/carbuncle/

11. https://www.pinterest.com/pin/455637687272631453/

12. ERYSIPELAS
http://diseasespictures.com/erysipelas/

13. CELLULITIS
http://billqualls.com/survival/cellulitis/index.html

14. http://billqualls.com/survival/cellulitis/index.html

15. http://billqualls.com/survival/cellulitis/index.html

16. NECROTIZING FASCIITIS
http://www.sailinglinks.com/vanuatu.htm

17. NF AFTER DEBRIDEMENT
http://www.sailinglinks.com/vanuatu.htm

18. WITH VACUUM DRESSING
http://www.sailinglinks.com/vanuatu.htm

19. RESOLVED
http://www.sailinglinks.com/vanuatu.htm

20. NECROTIZING SOFT TISSUE INFECTION
(FASCIITIS: NF)
• Extremely high mortality rate (80-100%) if delay treatment
• 16-24% in rapid recognition
• “gas gangrene, rapidly spreading cellulitis, and necrotizing fasciitis”
• Risk factors:
• elderly
• Immunosuppressed including diabetes
• Peripheral vascular disease

21. NECROTIZING SOFT TISSUE INFECTION
• Highly suspected in sepsis with minimal wound
• History:
• within 1 -2 days
• Pain out of proportion
• Examination:
• Greyish, turbid semipurulent material (dishwater pus)
• Skin changes: bronze color or brawny induration
• Blebs (hemorrhagic)
• crepitus

22. NECROTIZING FASCIITIS

23. DISHWATER PUS
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 153

24. NECROTIZING SOFT TISSUE INFECTION
• Common organisms: mixed
• Streptococcus pyogenes
• Pseudomonas aeruginosa
• Clostridium perfringens
• Investigation:
• only lab
• imaging is not recommended due to delay intervention (US might be used)

25. NECROTIZING SOFT TISSUE INFECTION
• Treatment:
• Emergent aggressive and radical debridement
• Direct visualization of potentially infected tissue
• Immediate IV antibiotics cover all gram-positive and negative aerobes, and
anaerobes
• Septic shock resuscitation

26. NECROTIZING SOFT TISSUE INFECTION: AFTER DEBRIDEMENT
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 153

27. OSTEOMYELITIS

30. FOURNIER’S GANGRENE

33. HAND INFECTION
• Paronychia
• Felon
• Pyogenic flexor tenosynovitis
• Bursal infection
• Web space abscess
• Dorsal hand abscess
• NF of upper extremities

34. MICROBIOLOGY
• Staphylococcus aureus
• MRSA
• Mixed aerobe and anaerobe organisms in immunocompromised host
• Human bites: Eikenella corredens
• Dog and cat bites: Pasteurella multocida
• Maine animal: Vibrio
• gas gangrene: Clostidium perfringens, Streptococcus pyogenes, S.aureus,
Vibrio vulnificus, polymicrobial

35. PARONYCHIA
• Infection involving tissue surrounding
the fingernail
• Most organism: S.aureus
• Treatment:
• Warm soaks
• I & D if abscess
• Nail plate removal

36. FELON
• Abscess at pulp of fingertip
• Treatment:
• Warm soaks
• Elevation
• Antibiotics
• Surgical decompression

37. PYOGENIC FLEXOR TENOSYNOVITIS
• Kanavel: cardinal signs:
• Tender along sheath
• Fixed flex position of finger
• Pain on passive extension
• Fusiform swelling finger
• Treatment:
• Conservative if early and healthy patient
• Surgery: debridement and flushing
tendon sheath

38. PYOGENIC FLEXOR TENOSYNOVITIS

39. BURSAL INFECTION
• Extending infection of tenosynovitis
to Parona’s space
• Treatment:
• Aggressive debridement under GA

40. DEEP SPACE INFECTION
• Thenar, hypothenar, and midpalmar space abscess
• Web-space abscess (collar-button)
• Dorsal hand abscess
• Osteomyelitis

42. CONCLUSION…
• Skin and soft tissue infection >>> purulent VS non-purulent
• Always assess severity
• Purulent >> I & D
• Non-purulent with septic shock >> always rule out NF