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Hand Infections PowerPoint Presentation

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This medical PowerPoint presentation is about hand infections which can occur for a variety of reasons, including cuts, puncture wounds, animal bites, or as a result of surgery. These infections can be painful and can cause swelling, redness, and warmth in the affected area. If left untreated, hand infections can lead to serious complications, such as tendonitis, nerve damage, or even amputation.

Treatment for hand infections usually involves antibiotics and in some cases, surgical drainage. It is important to seek medical attention as soon as possible if you suspect you have a hand infection. In the meantime, you can take steps to manage the symptoms, such as elevating the affected hand and using over-the-counter pain relievers.

To prevent hand infections, it is important to practice good hand hygiene by washing your hands regularly with soap and water or using an alcohol-based hand sanitizer. If you have a cut or wound on your hand, keep it clean and covered with a sterile bandage until it has fully healed. Additionally, avoid touching your face or other peoples wounds to prevent the spread of bacteria.

Tags : Hand Infections, Cellulitis, Abscess, Paronychia, Felon, Herpetic whitlow, Hand Surgery, Hand Surgery PowerPoint presentation

Published on : May 29, 2023 | Views : 679 | Downloads : 1

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Hand Infections
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Hand InfectionsIntroduction In the pre-antibiotic era: 65% of hand disability resulted from minor injuries that became infected 50 - 75% of all hand deformities were the result of infection Kanavel’s study of the surgical anatomy of the hand: defined anatomical planes and channels careful placement of incisions for optimal drainage became the cornerstone of treatment in the pre-antibiotic era Penicillin changed the landscape: severe hand infections are relatively uncommon today incidence stable since 1940’s
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Hand InfectionsAntibiotics valuable adjunct in infections but used alone will effect a cure in only a limited number of situations early diagnosis: 24 - 48 hrs. high dose IV therapy elevation & splinting to rest the affected part Beyond this time success is unlikely: thrombosis of small vessels swelling & pressure within closed anatomical spaces Abx need not be continued more than 7 - 10 days exception: osteomyelitis can usually switch to oral route in 2 - 3 days (if improving)
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Hand InfectionsOutline Principles High Risk Patients Felons & Paronychia Flexor Tenosynovitis Deep Space Infections Bites IDU Osteomyelitis Septic Arthritis Chronic Infections
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Hand InfectionsIntroduction Treatment principles early & adequate decompression of pus to avoid soft tissue loss proper placement of incisions avoids damage to adjacent structures minimizes scar contracture appropriate debridement of necrotic tissue judicious splinting & early mobilization to minimize joint stiffness appropriate use of Abx as adjunct to prevent dissemination of established infection
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Hand Infections Introduction For infections requiring drainage, pre-operative planning is required. Type & placement of incision should: Allow direct access to the abscess cavity Permit easy extension in any direction Follow accepted principles of hand surgery
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Hand Infections Introduction Principles: carry out procedure with optimal lighting, positioning, visualization, analgesia & tourniquet control Do not exsanguinate part as this may cause bacterial seeding incisions don’t cross flexion creases at > 45° avoid injury to vessels, nerves & tendons avoid compromising the blood supply to adjacent area avoid leaving a sensitive scar, especially in an important tactile area wounds left open are packed for 48 - 72 hrs. followed by saline soaks & exercise
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Hand InfectionsHigh Risk Patient Up to 50% of hand infections involve: Diabetic / Immune compromised IDU Bites Higher risk for developing severe complications: Joint stiffness - Osteomyelitis Contracture - Necrotizing Fasciitis Amputation - Death
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Felons & ParonychiaGeneral Account for ~ 1/3 of hand infections
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Felons Anatomy of the fingertip Distal phalanx is a closed sac separate from the remainder of the digit Closed pulp space divided into a latticework by multiple septa Interstices filled with eccrine glands & fat Dorsum is rigid (bound by DP & perionychium) An increase in pressure of this compartment can adversely affect the blood supply to the soft tissue & bone.
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Felons palmar closed-space infection of the distal pulp severe pain, redness & swelling Hx of minor penetrating trauma is usually present: Minor cuts Splinters Glass slivers most frequent causative agent: S. Aureus untreated felons can: extend toward the phalanx --> osteomyelitis toward the skin --> draining sinus obliterate vessels ---> skin slough or necrosis supperative flexor tenosynovitis or septic arthritis of the DIPJ
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FelonsTreatment If recognized early (mild cellulitis): soaks & Abx Later (abscess formation): surgical drainage Usually process has been going on > 48 hrs. Principles: Avoid injury to n/v structures Utilize an incision that won’t leave a disabling scar Do not violate flexor sheath (stay distal) Produce adequate drainage
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FelonsTreatment Multiple incisions described: Fishmouth J or hockey stick Through & through Volar transverse Midvolar longitudinal Unilateral high midlateral Poor choices: - painful scar - unstable tip - anaesthetic tip Risks injury to digital nerve
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FelonsTreatment Palmar incisions through the center of the pulp Avoid crossing the DIP flexion crease (contracture) Blade should only penetrate the dermis to avoid n/v structures and then a clamp is used to spread the subcutaneous tissue typically, drain over area of maximal tenderness or sinus Disadv:: scar over tactile surface, risk injury to dig. nerve
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FelonsTreatment Unilateral longitudinal Incision Best approach for most felons Incise on lateral aspect of digit 5mm dorsal & distal to the DIP flexion crease Continue distally to a point 5mm away from the edge of the free nail Deepen the incision with a clamp within a plane just volar to the palmar cortex of the DP Location of Incisions: Index, middle & ring: ULNAR SIDE Thumb & small: RADIAL SIDE
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ParonychiaAnatomy
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Paronychia infection in and around the nail fold Acute: any break in the seal between the nail and nail fold may serve as a portal of entry for infection hangnails manicures nail biting usual causative agent: S. Aureus in more advanced infections, pus may accumulate beneath the nail plate, separating it from the underlying nail bed. This infection involves the entire eponychium and is called an “eponychia” Pus can also spread around the nail fold resulting in a “runaround infection”
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ParonychiaTreatment If recognized early (mild cellulitis): soaks & Abx Larger infections: drainage through the nail fold Paronychial fold & portion of adjacent eponychium: Remove 1/4 of nail If this doesn’t allow drainage, incise fold away from matrix
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ParonychiaTreatment Eponychia: Elevate eponychial fold and excise prox 1/3 of nail Lateral (paronychial) incisions may aid in separating the nail base if not already separated
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Chronic Paronychia Slightly different disease process with an indolent course marked by exacerbations & remissions Etiology: proximal nail fold obstruction + fungal infection Often seen in people whose hands are constantly in a moist environment Inflammation of the eponychial fold, often with separation from the underlying nail and intermittent drainage usual causative agent: fungus > gram negative bacteria Tx: eponychial marsupialization + topical antifungal Crescent-shaped piece of skin excised proximal to nail fold medical tx alone is largely unsuccessful
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TenosynovitisAnatomy Flexor sheaths are closed spaces Extend from the mid-palmar crease to the DIPJ (Prox edge of A1 pulley to distal edge of A5 pulley) Flexor sheath of small finger is continuous proximally with the Ulnar Bursa, while the sheath of the thumb is continuous with the Radial Bursa Radial & Ulnar bursae extend proximal to the TCL and connect with the Parona space(Potential space between FDP & PQ muscle)
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TenosynovitisGeneral Flexor sheath infections most often as a result of penetrating trauma More likely at joint flexion creases Sheaths are separated from skin by only a small amount of subcutaneous tissue here Also, Felons can rupture into the distal flexor sheath Usual causative agent: S. Aureus most commonly affected digits: Ring, long & index fingers
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TenosynovitisGeneral Purulence within the sheath destroys the gliding mechanism, rapidly creating adhesions that lead to loss of function destroys the blood supply producing tendon necrosis
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TenosynovitisClinical Kanavel’s 4 cardinal signs: Tenderness over & limited to the flexor sheath Symmetrical enlargement of the digit (“fusiform”) Severe pain on passive extension of the finger (> proximally) Flexed posture of the involved digit Not all four signs may be present early on Most reliable sign: pain w. passive extension Cellulitis of the hand may appear similar, but swelling & tenderness is not usually isolated to a single digit
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TenosynovitisTreatment Early infection < 48 hrs (& usually lacking all 4 signs) may initially be treated with IV Abx, splinting & elevation Failure to respond within 24 hrs. should necessitate drainage Established pyogenic tenosynovitis is a surgical emergency Requires prompt surgical drainage Delays may result in tendon &/or skin necrosis
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TenosynovitisTreatment 2 basic approaches: Open vs. Closed Open drainage: Decompression of the entire tendon sheath via mid-axial & palmar incisions Wounds are left open to drain & heal secondarily Rehab is prolonged; permanent finger stiffness not infrequent Most useful for advanced cases where resection of necrotic tendon is required
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TenosynovitisTreatment Closed tendon-sheath irrigation: 2 incisions made Proximal palm: open the sheath proximal to the A1 pulley Distal mid-axial: open sheath distal to the A4 pulley Long irrigation catheter (16 - 18g) is placed in the proximal sheath with a drain left in the distal incision Incisions are then closed, and sheath is irrigated for 48 - 72 hrs. May use NS or Abx solution (continuous drip or q2h flush) Addition of marcaine alleviates pain of irrigation Modification involves multiple transverse incisions of cruciate pulleys with insertion of silastic drains
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TenosynovitisTreatment These incisions: ensure adequate drainage heal quickly Do not interfere with rehab After removal of catheter and drains begin gentle passive & active ROM
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Chronic Tenosynovitis Unusual cases may be seen which present differently than acute pyogenic infections: Chronic swelling of the flexor sheath No disabling pain or loss of function These are chronic infections most frequently caused by mycobacteria usually the result of a puncture wound in an aquatic environment M. Kansasii or M. Marinarum Dx: AFB stains & culture of synovium Tx: tenosynovectomy + antituberculous drugs (6 - 24 mo)
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Deep Space Infections 4 deep spaces clinically significant in hand infections: Subfascial palmar space Dorsal subaponeurotic space Thenar space Midpalmar space
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Deep Space InfectionsSubfascial Palmar Space Infections subfascial palmar space communicates with the dorsal subcutaneous space via web spaces between the digits usually spread dorsally (“collar button abscess”) Double abscess: +/- palmar & dorsal abscesses connected through hole in fascia Palmar spread is limited by the relationship of fascia to skin Causes: Fissure in the skin between the fingers Distal palmar callus (MC head) Extension from subcutaneous infection in proximal finger Severe distal palmar swelling with an abducted finger Puss-filled web spaces
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Subfascial Palmar Space InfectionsTreatment 2 important points: Do not incise web space transversely Be alert for the double abscess configuration Drainage is via a palmar approach with division of the palmar fascia to expose both the volar & dorsal compartments
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Deep Space InfectionsDorsal Subaponeurotic Space Infections DSS is beneath the extensor tendons on the dorsum of the hand Often the result of penetrating trauma IDU’s neglected human bites Dorsal swelling, erythema & tenderness + history make the diagnosis Drain via linear incisions over the 2nd & 4th MC’s while preserving soft tissue coverage over the tendons occasionally direct incision over a pointing abscess is necessary Risks exposure (desiccation) of extensor tendons
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Deep Space InfectionsThenar Space Infections Thenar space follows the direction of Adductor Pollicis: Dorsal: AP muscle Volar: index flexor & 1st lumbrical Radial: insertion of AP (proximal phalanx of the thumb) Ulnar: oblique septum from skin to the 3rd MC
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Thenar Space InfectionsClinical Causes: penetrating injury thumb or index subcutaneous abscess thumb or index flexor tenosynovitis extension from radial bursa or midpalmar space marked swelling of the thenar eminence & 1st web space thumb forced into abduction severe pain with extention or opposition infection tracks dorsally via 1st web space, over the AP & 1st dorsal interosseous muscles.
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Thenar Space InfectionsTreatment Drain via volar or dorsal incisions in the 1st web space or both: Identify neurovascular structures unroof the adductor fascia to open the abscess cavity irrigate & debride catheter in volar incision & close; penrose in dorsal incision & close compressive dressing & plaster splint
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Deep Space InfectionsMidpalmar Space Infections Boundaries: Dorsal: intrinsic muscles Volar: flexor tendons Radial: oblique septum from the skin to the 3rd MC Ulnar: hypothenar muscles Distal: vertical septa of palmar fascia Prox: fascial layer at distal carpal tunnel
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Deep Space InfectionsMidpalmar Space Infections Clinical: usually due to direct penetrating trauma, rupture of tenosynovitis loss of palmar concavity, dorsal swelling, tenderness volarly
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Midpalmar Space InfectionsTreatment Drain via wide palmar incisions with +/- resection of palmar fascia to ensure drainage of abscess cavity. or may place irrigation catheter & drain and close primarily.
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Bursal Infections Usually due to spread of flexor tenosynovitis from thumb or small finger Radial bursa: Proximal extension of tendon sheath of FPL extends through the carpal tunnel into the distal forearm Ulnar bursa: Proximal extension of tendon sheath of FDP of small finger
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Bursal InfectionsTreatment Closed irrigation using 2 incisions, a catheter & a drain as previously outlined.
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Human Bites Often undertreated & misdiagnosed leading to significant morbidity The most serious form of human bite infection is the clenched fist injury: Any laceration over the head of a metacarpal is a human bite injury until proven otherwise
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Human Bites The wound that results from a punch to the mouth may appear insignificant and treatment may not be sought for days. It often results in immediate inoculation of the subcutaneous tissue, the subtendinous space and the MCP joint with saliva Human saliva may contain over 108 microorganisms per ml. Over 42 species of bacteria identified Thus: Polymicrobial infection is the rule Common organisms: S. Aureus, Strep sp., Eikenella: gram neg facultative anaerobe in ~ 30% (incr. severity)
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Human Bites Delay in onset of treatment is directly proportional to poor outcomes: In general, human bites treated within 24 hrs. rarely have serious complications in E.D.: Debride, irrigate, pack open Abx to cover gram +’s & eikenella (Pen & Ceph) +/- admission to follow response To O.R.: Established joint space penetration, & more severe infections
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Animal Bites Dog more common than cat (5%) Cat bites are particularly virulent & can result in deep puncture wounds that are hard to clean More than half involve kids Basic principles of debridement & irrigation apply Deep puncture wounds are left open & may require extension Established infections are debrided & packed open Superficial lacerations may be loosely closed after irrigation Common organisms: S. Aureus, Strep viridans, Pasturella (#1 in cats), anaerobes Abx: ampicillin (Clavulin on outpatient basis)
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Injection Drug Use Common sites of infection: Dorsum of hand Radiodorsal area of the wrist Palmar aspect of the forearm Dorsum of the fingers at the PIPJ Clinical spectrum: Cellulitis Subcutaneous abscess Flexor tenosynovitis Septic joints Osteomyelitis Necrotizing fasciitis
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Injection Drug Use Source of infection from a variety of sources Skin Saliva Bowel Tx: Admission elevation of limb broad spectrum IV Abx analgesia (may need support from APS or CDRT) +/- debridement & irrigation Medicine consult
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Hand InfectionsOsteomyelitis Almost always the result of adjacent spread wound infection joint infection tenosynovial infection Also, direct penetration (hematogenous spread is rare) most commonly S. Aureus Bone necrosis: hallmark microorganisms reside in dead bone If caught early, before extensive bone necrosis occurs, it may be cured with Abx alone.
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Osteomyelitis Diagnosis Xrays: Early radiographs may be normal It takes at least 10 days for matrix to mineralize & areas of increased density to be detected. Lytic lesions; sclerosis (1 month) Bone Scan: Can pick up osteomyelitis early, but less specific Prompt surgical exploration is the most reliable way to establish the diagnosis
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Osteomyelitis Treatment Approach depends on location of involved bone: Phalanx: mid-axial incision Metacarpals: dorsal approach all infected bone must be removed Soft bone may be curetted may need to use drill holes to remove a small window of cortical bone for decompression of the infection routine post-Op care or may also use constant irrigation methods (1 wk) severe, extensive involvement of a digit may be best treated by amputation Will prevent stiffness & major disability of the uninfected parts
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Hand InfectionsSeptic Arthritis usually the result of penetrating trauma: bite or tooth wound also, spread from soft tissue or bony infection joint is swollen, warm & tender pain with axial loading passive motion is restricted & painful Xrays: thinning of joint (cartilagenous loss) resorption of subchondral bone osteomyelitis (late) aspiration of joint for C & S
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Septic ArthritisTreatment Drainage is imperative as soon as the diagnosis is made Destruction of the articular cartilage by lysozymal activity approach is through a longitudinal dorsolateral incision over the affected joint access to the joint is via an incision dorsal to the cord portion of the collateral ligament joint is irrigated & debrided packed open for 48 - 72 hrs. (or closed over irrigation) packing removed and gentle ROM begun wound granulates closed
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Hand InfectionsChronic Infections Atypical mycobacterium infections: penetrating wound often in a marine environment prolonged, relatively non-painful swelling of finger, palm or wrist Tuberculous & atypical mycobacteria have a predilection for synovial tissue of joints & tendon sheaths Tenosynovium is thick, infected & hypertrophic. It surrounds the tendons & erodes the pulleys. Dx: culture synovial biopsy Noncaseating granulomas & AFB Tx: thorough joint synovectomy For ++ joint damage: rest the joint until the infection is cured before undertaking reconstruction For tenosynovium: complete synovectomy sparing the pulleys Start anti-TB meds empirically (around time of synovectomy)
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Hand InfectionsChronic Infections Tuberculous Infections: less common now than several decades ago Presents in a similar manner as atypical mycobacterial infections Tx: as above, synovectomy + anti-TB drugs In addition, can produce a dactylitis Enlarged fingers Proliferation of subperiosteal reaction on Xray Tx: surgical excision & curettage of the involved areas
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Hand InfectionsChronic Infections Leprosy: M. lepraemurium Predilection for cooler areas of the body including the hands Most frequently produces a neuropathy involving the ulnar nerve: intrinsic atrophy clawing weakness in pinch Tx: surgical procedures limited to reconstruction for the neurological deficits
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Hand InfectionsChronic Infections Fungal Infections: except for biopsy for diagnostic purposes, surgical treatment is rarely necessary best treated with systemic &/or local anti-fungal agents occasionally a tenosynovitis, septic arthritis or osteomyelitis is seen: Appropriate debridement required as above Mainstay is still anti-fungal agent
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Post Op Care Wound care & early initiation of therapy are key in achieving good functional results in treating hand infections In general: wounds are debrided, irrigated & packed open packing usually removed 24 - 48 hrs. post-op initiation of regular wound cleansing gentle active ROM splints may be helpful in enhancing joint motions early involvement of a hand therapist is important in achieving a good functional result.
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