2.
approx 35% of patients admitted to hand surgery
services.
Majority are result of minor trauma for which
treatment is delayed or neglected.
Occasionally these are results of drainage efforts by
patients themselves under aseptic conditions.
3.
4.
Uncomplicated Infections:
Antiobitics alone will suffice.
Evolved infections with localized collections:
Antiboitics
Drainage.
5.
Any surgeon who accepts the responsibility for
drainage of a hand infection must undertake
comprehensive management responsibilities including:
Preoperative Planning
Surgical Approach
Postoperative Care
Rehabilitation.
6. A. Evaulation
B. Operative Principles
C. Rest/Heat/Elevation
D. Inpatient Care
7. A: EVALUATION
HISTORY:
o Reveals the source of infection or predisposing factors.
o Previous injury to the site
o Bites --- Splinter --- Needle sticks --- surgical procedure
o Hand Dominance & Occupation
o exposure to certain pathogens.
o History of Systemic diseases like DM,
immunocompromised states.
8.
SYMPTOMS:
o Timing of events
o Pain
o Loss of function
o Drainage
o Fever
o Chills.
9.
Physical Examination:
o Exposure of whole extremity
o Signs of lymphangitis and lymphadenopathy
o A systemic approach to avoid missing critical
information.
10.
RADIOGRAPHS:
o Retained foreign bodies
o Rule out osteomyelitis
o Gas gangrene
o Serve as baseline for future comparison.
11. A. Evaulation
B. OPERATIVE PRINCIPLES
C. Rest/Heat/Elevation
D. Inpatient Care
12. B: OPERATIVE
PRINCIPLES
1. Incisions should never cross a flexion crease at a
right angle
2. Avoid iatrogenic injury to critical structures
1. Tendons
2. Neurovascular bundles
3. Incision lengthening is usually needed and should
be planned by making potential extensions with a
pen.
13.
4. Torniquet Control is helpful as infective process
can lead to profuse bleeding.
o Finger Torniquet
o Penrose drain
o Glove technique
o Standard Pnematic Torniquet with exanguination
o Esmarch bandage
o Elevation of limb with digital pressure on brachial
artery.
14. A. Evaulation
B. Operative Principles
C. REST/HEAT/ELEVATION
D. Inpatient Care
15. C: REST – HEAT -
ELEVATION
a. REST (IMMOBILIZATION)
o Limits opening of tissue plans restricting the spread
of infection.
o Should be done in a functional position.
16.
b. HEAT (WARM MOIST SOAKS):
o Maximum vasodilatory effect reached in 10 min.
o Frequent soaks preffered over continous soaks.
o Severe Infections:
o Moist hot towels with plastic barrier and a dry towel as
insulator.
17.
c. ELEVATION:
o Reduces edema by improving venous/lymphatic
drainage.
o Limb should be above level of heart for dependant
drainage.
o Limb placed over chest or on a pillow while sitting.
18. A. Evaulation
B. Operative Principles
C. Rest/Heat/Elevation
D. INPATIENT CARE
19. D: INPATIENT CARE
IV antiboitcs is the most common justification for
hospitalization.
Continuous or intermittent wound irrigation.
Frequent dressing changes.
Three phases of treatment in cases of severe
infections where extensive debridement and
complex reconstructions are needed.
20.
Phase 1> Rapid infection contrtol and staged
debridement.
A second look surgery done in 24-48 hours.
Phase 2> Salvage of vital structures and soft tissue
coverage.
With identification of structures that will later require
reconstruction.
Phase 3 > Reconstructive Surgery.
Once stable soft tissue coverage is achieved.
21. ANTIMICROBIAL
THERAPY
Antiboitcs are indespensible adjuncts.
Cultures should be obtained prior to antiboitics use.
Most common pathogens involved are Staph aures
and Streptococcus sp.
Usually gram +ve coverage is first choice.
Consider MRSA while treating infections depending
upon patterns of resistance in a particular area.
22. ACUTE PROCESSES:
A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. Septic arthritis
I. Necrotizing Fascitits.
23. A. CELLULITIS
Virtually all hand infections begin as cellutitis.
Symptoms:
Pain
Swelling
Erythema
Lymphadenopathy
Lymphangitis.
24.
Treatment:
Oral antiboitics (usually gram +ve coverage)
Rest
Warm soaks
Elevation.
LYMPHANGITIS > Cellulitis accompained by
erythematous streaks up the arm.
25. ACUTE PROCESSES:
A. Cellulitis
B. PARONYCHIA
C. Felon
D. Palmer space infections
E. Pyogenci (Supparative) Flexor Tenosynovitis
F. Bite wounds
G. Septic arthritis
H. Necrotizing Fascitits.
26. B: PARONYCHIA
Infection of the soft tissues surrounding the
fingernail and is the most common infection of
hand.
29.
Cause:
Inocculation of bacteria as a consequence of minor
trauma such as
Nail bitiing
Poor manicuring
Small puncutre wounds.
Staph aureus is most common pathogen but
anaerobes may also be involved.
30.
UNCOMPLICATED INFECTION:
Oral antiboitics / Rest / Heat / Elevation
INFECTION WITH ABCESS:
Localized to one nail fold;
Elevation of fold bluntly with a haemostat
Using no 11 blade directing away from nail bed through
the insensate epithelium where abcess is pointing.
31.
Eponychia (involving proximal nail & one lateral fold;
Elevating the eponychial fold and removal of loose
portion of nail plate to drain abscess and allow for
secondary healing.
32. ACUTE PROCESSES:
A. Cellulitis
B. Paronychia
C. FELON
D. Palmer space infections
E. Pyogenci (Supparative) Flexor Tenosynovitis
F. Bite wounds
G. Septic arthritis
H. Necrotizing Fascitits.
33. C: FELON
A felon is an abscess of the distal pulp of the
thumb or finger.
35.
Pulp Anatomy:
15-20 longitudonal septa anchoring skin to distal
phalanx dividing the pulp into multiple closed
compartments.
36.
Pathophysiology:
Abscess formation within these small compartments
results in rapid development of swelling and
throbbing pain, worsened by dependency.
Complications:
Necrosis of entire pulp
Extension of infection into;
Flexor tendon sheath
Distal IP joint
Distal phalanx.
37.
Causes:
Mostly Puncture wound with foreign body, so radiographs
are mandatory.
Pathogen:
Staph aureus but gram –ve infection can also occur esp in
immunocompromised patients.
Conservative Management: For early Felons…
Oral antiboitics
Rest
Warm Soaks
Elevation.
38.
Basic principles of Incision drainage;
Avoid iatrogenci injury to neurovascualar structure
Leave an acceptable scar
Avoid flexor tendon sheath
Drain all fluid collections adequately.
Two types of INCSIONS:
Volar Longitudonal incision
Hockey stick or J- inscion
40. ACUTE PROCESSES:
A. Cellulitis
B. Paronychia
C. Felon
D. Herpetic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. Septic arthritis
I. Necrotizing Fascitits.
41. D: HERPETIC
WHITLOW
Herpex simplex virus infection can be:
Primary
Recurrent
Population at risk:
Children, adolesents with genital herpes infection
Health care workers with frequent exposure to oral
secretions.
Must be distinguished from Paronychia and Felon
because incision and drainage is generally
contraindiacted.
43.
Pathophysiology:
A prodromal phase of 24-72 hours of burning pain
prior to the development of skin changes.
Erythema and swelling
Formation of clear vesicles which sometimes coalsease
around nail fold.
Fluid may become turbid but not frankly purulent
unless bacterial superinfection occurs.
Pulp of affected digit is not tense as in felon.
45.
Disease Course:
The process occurs over approx 2 weeks and resolves over
next 7-10 days.
Diagnosis:
Viral culture
Tzanck smear
Treatment: Generally conservative
Rest & Elevation
Anti inflammatory agents
Acyclovir in immunocompromised states.
Reccurence rates are around 20%.
46. ACUTE PROCESSES:
A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. PALMER SPACE INFECTIONS
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. Septic arthritis
I. Necrotizing Fascitits.
47. E: PALMER SPACE
INFECTIONS
Thenar space
Midpalmer space (subtendinous space)
Hypothenar space
Dorsal subapeneurotic space
Web spaces.
Thenar and midpalmer spaces are clinically more
important.
48.
THENAR SPACE
INFECTION
MIDPALMER SPACE
INFECTION
49.
A penetrating injury usually a splinter is the most
common cause.
Staph aureus is the usual pathogen.
Antiboitics / Rest / Heat / Elevation for early
infections but most cases need Surgical Drainage.
Key to success is adequate drainage while avoiding
iatrogenic injury and subsequent scar contracutres.
50. Midpalmer space infection
incisions and proceedures:
Curved longitudonal incision in the palm.
Take care to avoid injury to superficial palmer arch
and digital vessels.
Wound packed open with daily dressing changes.
OR
Irrigation catheter in proximal wound and a penrose
drain in distal wound for continous or intermittent
irrigation.
51. Thenar space infection
incision and procedure:
Combined dorsal and volar incisions.
Take care to avoid injury to palmer cutaneous
branch of median nerve in proximal end of incision
And avoiding injury to motor branch of median
nerve.
Post op care include
Splinting
Dressing changes
Catheter irrigation.
53. ACUTE PROCESSES:
A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. PYOGENCI (SUPPARATIVE) FLEXOR TENOSYNOVITIS
G. Bite wounds
H. Septic arthritis
I. Necrotizing Fascitits.
54. F: PYOGENIC (SUPPARATIVE)
FLEXOR TENOSYNOVITIS:
Most serious hand infection.
If left untreated;
Destruction of gliding
surfaces in sheath
Necrosis of tendons
Osteomyelitis
Amputation.
Ring, middle and index fingers mostly involved
Staph aureus usual pathogen with few cases due to
haematogeneous spread of gonococcal infection.
56.
KANAVEL cardinal sign of flexor
tenosynovitis:
1. Fusiform swelling of finger
2. Paritally flexed posture of digit
3. Tenderness over entire flexor sheath
4. Dipropotionate pain on
passive extension.
57.
< 48 hours of onset of infection:
IV antiboitics
Rest / Heat / Elevation
> 48 hours of onset of infection:
Surgical drainage with zig zag brunner incisions
Wound is packed open and loosely approximated
Early and aggressive hand therapy initiated.
Less severe cases:
Catheter irrigation with limited incision .
58. ACUTE PROCESSES:
A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. BITE WOUNDS
H. Septic arthritis
I. Necrotizing Fascitits.
60. a. Human bites:
Potenitally serious due to high virulence of pathogens
invovlved.
Common mechanism is clenched fist striking a
tooth, FIGHT BITE.
Usually delayed presentation.
Most commonly over the MCP joint, putting the extensor
mechanism and joint surface at risk.
Radiographs are mandatory and may reveal;
Tooth fragment
Fracture of Metacarpel head
Air in joint.
61.
All human bites in MCP joint region should be
explored;
Joint space irrigated
Edges debrided
Primary wound closure never done.
Closed after a week or 10 days
in severe cases
Antiboitics / Rest / Heat / Elevation
Usually covering gram +ve and anaerobes.
62. b. Animal bites:
Domestic Dogs and Cats
Tetnus status should be ensured.
Rabies prophylaxis
Thorough irrigation and exploaration of
joints when potentially voilated.
64.
CAT bites can present late with closed space
abscesses due to trapping of bacteria inside wounds
65.
CAT scratch FEVER;
Small pustule with surrounding edema at site of cat
bite
Painful lymphadenopathy
Symptomatic treatment
Anti inflammatory
Antiboitics
Pain resovlves in 2 weeks but lymphadenopathy can
persist for months or years.
66. ACUTE PROCESSES:
A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. SEPTIC ARTHRITIS
I. Necrotizing Fascitits.
67. H: SEPTIC ARTHRITIS
Destruction of articular surfaces.
Mode of infection:
Penetrating injury
Local extension of adjacent infection
Haematogenous spread (Gonococcal infection)
Children;
Streptococcus sp
Staph aureus
H. Infulenza
Adults; with no history of trauma
Suspect Gonococcus.
68.
Presentation; Septic joint will be
Swollen
Tender
warm
Marked pain on passive motion.
Patient position of hand is to allow maximum joint
space;
IP joints in 30 degree flexion
MCP full extension
69.
Exploration is mandatory and joints are copiously
irragated and debrided.
Joint packed open and dressing changes performed.
Wound left to close by secondary intention.
Antiboitics
Rest / Heat / Elevation.
70. ACUTE PROCESSES:
A. Cellulitis
B. Paronychia
C. Felon
D. Herptic Whitlow
E. Palmer space infections
F. Pyogenci (Supparative) Flexor Tenosynovitis
G. Bite wounds
H. Septic arthritis
I. NECROTIZING FASCITITS.
71. I: NECTROTIZING
FASCITIS
A life threatening, rapidly progressing infection of
the subcutaneous tissue and fascia.
Diabetics and immunocompromised patients are at
greater risk.
72.
Pathogenesis;
Low grade cellulitis bullous changes in
skin cutaneous anesthesia with spread
into underlying subcutaneous tissuefat
necrosisvascular
thrombosiMyonecrosiscutaneous
vessel thrombosis.
73.
Mixed infection;
Aerobes
Anaerobes
Clostridium sp result in gas formation in tissues with
crepitus on physical exam and air in tissues on
radiographs.
Treatment:
Repeated aggressive radical debridements
Amputations above area of involvement
Silvadene cream
IV High dose antiboitics and tissue culture
Hyperbaric O2.
74. CHRONIC
INFECTIONS:
A. CHRONIC PARONYCHIA
B. OSTEOMYELITIS
C. ONCHOMYCOSIS
D. VIRAL INFECTIONS
E. MYCOBACTERIAL INFECTIONS
75. A: CHORNIC
PARONYCHIA
Presentation: Eponychium is;
Indurated
Erythamatous
Occasional drainage from nail fold.
Population at risk;
Diabetics
Frequent occupational exposure to moist conditions
CANDIDA ALBICANS is the most common
pathogen.
76.
Medical Management:
Topical antifungal
Topical steroids
Removal of thickened, deformed nail plate.
Surgical Management:
Eponychial Marsupalization.
77. CHRONIC
INFECTIONS:
A. CHRONIC PARONYCHIA
B. OSTEOMYELITIS
C. ONCHOMYCOSIS
D. VIRAL INFECTIONS
E. MYCOBACTERIAL INFECTIONS
78. B: OSTEOMYELITIS
Mode of infection:
Direct extension from an adjacent infection
Septic arthritis
Flexor tenosynovitis
After open fracture
Haematogenous seeding.
Causative Bacteria:
Staph aureus
Hemophilus sp in young children.
79.
Presentation:
Chronically draining wound
Erythema
Pain
Swelling along the course of bone.
Diagnosis:
Radiographs
Bone scans
CT / MRI
Bone culture and bone biopsy (Gold standard)
Swab cultures
80.
Treatment:
Long term antiboitic use for 4-6 weeks even upto 6
months.
Spectrum kept broad at first, then narrowed based on
bone culture sensitivities.
Bone curettage during biopsy taking.
40% cases still need amputation.
81. CHRONIC
INFECTIONS:
A. CHRONIC PARONYCHIA
B. OSTEOMYELITIS
C. ONCHOMYCOSIS
D. VIRAL INFECTIONS
E. MYCOBACTERIAL INFECTIONS
82. C: ONCHOMYCOSIS
(TENIA UNGUIUM)
Infected nails appear thickened and discolored
Nail eventually separates from nail bed.
Nail appear flaky.
Causes:
Trichophyton rubrum most common
Candida albicans usually in diabetics.
Fungal cultures always obtained prior to antifungal
therapy.
83.
Trichophyton rubrum responds best to oral
Terbinafine.
Candida can be treated with;
Topical nystatin
Miconazole
Oral ketoconazole
Itraconazole
Griseofulvin.
Removal of nail plate may imporve
response for extensively involved nails.
84. CHRONIC
INFECTIONS:
A. CHRONIC PARONYCHIA
B. OSTEOMYELITIS
C. ONCHOMYCOSIS
D. VIRAL INFECTIONS
E. MYCOBACTERIAL INFECTIONS
85. D: VIRAL INFECTIONS
Warts are viral infections caused by Human Papilloma
Virus (HPV).
Types of warts;
1. Verruca vulgaris
95%
Rough
Raised cauliflowerlike appearance.
2. Verruca plana
5%
Smooth
Minimally elevated.
86.
Treatment options;
1. Keratolytic
70% success rate
Duration several days to several weeks
Salicylic acid preparations
2. Cryotherapy
Liquid nitrogen
Without anesthesia
Warts refractory to conservative management.
