Hand and finger infections: Difference between revisions

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===Treatment===
===Treatment===
*Mild/moderate cellulitis
*Mild/moderate cellulitis
**TMP/SMX DS 1-2 tab PO x 7-10d + (cephalexin 500mg PO QID x7-10d OR dicloxacillin 500mg PO QID x 7–10d
**TMP/SMX DS 1-2 tab PO x 7-10d + (cephalexin 500mg PO QID x7-10d OR dicloxacillin 500mg PO QID x 7–10d)
*Severe cellulitis
*Severe cellulitis
**Vancomycin 1gm IV q12hr
**Vancomycin 1gm IV q12hr
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===Background===
===Background===
*Result of striking another individual's teeth with clenched fist
*Result of striking another individual's teeth with clenched fist
*Most commonly affects dorsal aspects of third, fourth, and fifth MCP joints
*Although may appear benign, significant morbidity can result from late presentation or inadequate initial management  
*Although may appear benign, significant morbidity can result from late presentation or inadequate initial management  


===Clinical Features===
===Clinical Features===
The physical examination should document the extent of the infection. Hand x-rays are indicated because closed fist injuries are often associated with fractures, or may contain tooth fragments. Infections are typically polymicrobial. The most common organisms reflect the natural flora of the mouth and include Streptococcus species (82%), S. aureus (57%), E. corrodens (32%), Fusobacterium (27%), Peptostreptococcus (14%), and Candida (3.6%) species. If infection is detected or examination suggests injury to the joint, joint capsule, tendons, or deep spaces, a hand surgeon should be consulted for open debridement and irrigation in the operating room. Administer parenteral antibiotics. Elevate the hand and immobilize it in the position of function. Prophylactic antibiotics should be initiated for all but the most superficial wounds caused by a clenched fist
**Pain/swelling over dorsal aspect of MCP joint (most commonly third, fourth, and/or fifth MCP joints)
 
==Diagnosis==
*Imaging indicated to rule-out fracture, tooth fragments
 
==Treatment==
*Prophylactic abx should be initiated for all but the most superficial wounds
**If no visible signs of infection:
***Amoxicillin-clavulanate 875/125mg PO BID x5d
**For signs of infection:
***Ampicillin-sulbactam 1.5gm IV q6h OR cefoxitin 2gm IV q8h OR piperacillin/tazobactam 3.375gm q6h
***Penicillin allergy: clindamycin plus ciprofloxacin
 
==Paronychia==
===Background===
*Infection of lateral nail fold or perionychium
*Usually caused by minor trauma (e.g. nail-biting, manicures, hangnails)  
 
===Management===
*If no fluctuance is identified:
**Warm soaks, elevation
**TMP/SMX DS 1-2 tab PO x 7-10d + (cephalexin 500mg PO QID x7-10d OR dicloxacillin 500mg PO QID x 7–10d)
*If unclear if wound is fluctuant:
**Have pt apply pressure to distal aspect of affected digit
**A larger than expected area of blanching, reflecting a collection of pus, may identify the need for drainage
*If fluctuance or pus is identified:
 
.18 After suppuration has occurred, the infection will exhibit either fluctuance or identifiable pus that will necessitate drainage. Minor infections can be treated with elevation of the perionychium or eponychium with a flat probe #11 blade (Figure 280-5) or needle slid along the surface of the nail.19 If only elevating the eponychium from the nail, this procedure can be performed without placing a digital block or providing analgesia.20 In general, only nonviable tissue can be incised without provoking pain.




Revision as of 01:44, 25 February 2012

Background

  • Pts w/ systemic symptoms due to a hand infection are seriously ill; require inpatient management

Hand Cellulitis

Background

  • Remove rings if infections are near the digits

Clinical Features

  • Erythema, warmth, and edema
  • Range of motion of digits, hand, and wrist should not be painful
    • Pain predicts extensive involvement and the need for inpatient management

Treatment

  • Mild/moderate cellulitis
    • TMP/SMX DS 1-2 tab PO x 7-10d + (cephalexin 500mg PO QID x7-10d OR dicloxacillin 500mg PO QID x 7–10d)
  • Severe cellulitis
    • Vancomycin 1gm IV q12hr

Disposition

  • Consider admission for:
    • Immunocompromised
    • Clinical toxicity
    • Evidence of deep-space involvement
    • Rapidly spreading infections

Flexor Tenosynovitis

Background

  • Surgical emergency; flexor sheaths are contiguous w/ deep spaces of the hand
  • Usually associated with penetrating trauma

Clinical Features

  1. Percussion tenderness
    1. Tenderness over entire length of flexor tendon sheath
  2. Uniform swelling
    1. Symmetric finger swelling along length of the tendon sheath
  3. Pain w/ passive extension
  4. Flexion posture
    1. Flexed posture of involved digit at rest to minimize pain

Management

  1. Antibiotics
    1. Start immediately
    2. Vanco 1gm IV q12hr + (ampicillin-sulbactam 1.5gm IV q6h OR cefoxitin 2gm IV q8h OR piperacillin/tazobactam 3.375gm IV q6h)
  2. Consult hand surgery in the ED

Deep Space Infection

Background

  • Volar surface contains potential deep spaces that may become infected
  • Dorsal aspect contains the veins and lymphatics; will always swell whenever there is an inflammatory process

Clinical Features

  • Tenderness, induration, or fluctuance over volar aspect of hand
  • Pain w/ range of motion of digits

Management

  • Parenteral antibiotics
  • Hand surgeon consult

Closed Fist Infection "Fight Bite"

Background

  • Result of striking another individual's teeth with clenched fist
  • Although may appear benign, significant morbidity can result from late presentation or inadequate initial management

Clinical Features

    • Pain/swelling over dorsal aspect of MCP joint (most commonly third, fourth, and/or fifth MCP joints)

Diagnosis

  • Imaging indicated to rule-out fracture, tooth fragments

Treatment

  • Prophylactic abx should be initiated for all but the most superficial wounds
    • If no visible signs of infection:
      • Amoxicillin-clavulanate 875/125mg PO BID x5d
    • For signs of infection:
      • Ampicillin-sulbactam 1.5gm IV q6h OR cefoxitin 2gm IV q8h OR piperacillin/tazobactam 3.375gm q6h
      • Penicillin allergy: clindamycin plus ciprofloxacin

Paronychia

Background

  • Infection of lateral nail fold or perionychium
  • Usually caused by minor trauma (e.g. nail-biting, manicures, hangnails)

Management

  • If no fluctuance is identified:
    • Warm soaks, elevation
    • TMP/SMX DS 1-2 tab PO x 7-10d + (cephalexin 500mg PO QID x7-10d OR dicloxacillin 500mg PO QID x 7–10d)
  • If unclear if wound is fluctuant:
    • Have pt apply pressure to distal aspect of affected digit
    • A larger than expected area of blanching, reflecting a collection of pus, may identify the need for drainage
  • If fluctuance or pus is identified:

.18 After suppuration has occurred, the infection will exhibit either fluctuance or identifiable pus that will necessitate drainage. Minor infections can be treated with elevation of the perionychium or eponychium with a flat probe #11 blade (Figure 280-5) or needle slid along the surface of the nail.19 If only elevating the eponychium from the nail, this procedure can be performed without placing a digital block or providing analgesia.20 In general, only nonviable tissue can be incised without provoking pain.


Source

  • Tintinalli
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