ortho hand and finger 2

Infections of the Hand & Fingers

Felon

  • Definition: Infection of the distal phalanx, particularly the pulp region, accompanied by pus.

  • Common Pathogens:

    • Staphylococcus aureus

    • Gram-negative bacteria in immunocompromised patients

    • Eikenella corrodens in diabetic patients who bite their nails.

  • Etiology:

    • Causes include blood glucose issues, needle sticks, or splinters.

  • Complications:

    • Fingertip compartment syndrome.

    • Need for Tetanus prophylaxis.

Treatment for Felon

  1. Digital Block with Incision and Drainage (I&D).

  2. Antibiotics:

    • Oral antibiotics for mild infections.

    • IV antibiotics if the infection is severe, considering MRSA coverage.

Felon Surgical Approach

  • **Tips for Incision:

    • Keep incision distal to the DIP crease to prevent DIP flexion crease contracture and extension into the flexor sheath.**

  • Mid-lateral Approach:

    • For deep felons without foreign bodies.

    • Incision on the ulnar side for digits 2, 3, and 4, and on the radial side for thumb and digit 5.

  • Volar Longitudinal Approach:

    • Provides direct access for superficial felons, foreign body penetration, or visible drainage.

  • Incisions to Avoid:

    • Fishmouth incisions (can lead to unstable finger pulp).

    • Double longitudinal or transverse incisions (can injure the digital nerve and artery).

  • Debridement Protocol:

    • Avoid violating the flexor sheath or DIP joint to prevent infection spread.

    • Break up septa to decompress infection and prevent fingertip compartment syndrome.

    • Take gram stain and culture, hold antibiotics until culture results.

  • Postoperative Care:

    • Conduct routine dressing changes.

Paronychia

  • Definition: Infection occurring at the edge of the nailbed.

  • Differential Diagnosis:

    • Conditions like psoriasis and Reiter’s syndrome, which may mimic paronychia.

  • Treatment Protocol:

    • Apply warm compresses; Burow’s solution or vinegar may help.

    • Digital block with I&D if infection is severe (usually with an 11” blade).

    • Culture: For ruling out MRSA, especially in thumbsuckers and nail biters.

    • Coverage for anaerobes (e.g., Bacteroides) is important.

    • Use Augmentin or Cleocin as antibiotics.

Herpetic Whitlow

  • Definition: Appears as single or grouped blisters with a honeycomb appearance near the nail.

  • Diagnosis Confirmation:

    • Tzanck testing or viral culture.

  • Contraindications:

    • Incision and drainage is contraindicated in herpetic whitlow.

  • Treatment Options:

    • Suppressive therapy with a 7-to 10-day course of Acyclovir 5% ointment, cream (Zovirax), or an oral antiviral agent (Acyclovir, Famciclovir (Famvir), Valacyclovir (Valtrex)). Evidence from clinical trials is limited and needs consideration.

Flexor Tendon Sheath Infections

  • Anatomy: Flexor tendons are enclosed in a tenosynovial sheath extending from the distal palm to the DIP joint.

  • Etiology: Puncture wounds can lead to infections that progress to superficial infections of the hand.

  • Symptoms:

    • History of puncture wound on the flexor surface of the finger or thumb.

    • Progressive swelling of the affected digit.

    • Onset of pain develops 24-48 hours post-injury.

Flexor Tenosynovitis

  • Physical Examination (Kanavel Signs):

    1. Fusiform swelling of the finger (also known as ‘Sausage Finger’).

    2. Significant tenderness along the tendon sheath’s course.

    3. Marked increase in pain on passive extension.

    4. Flexed position of the finger at rest.

  • Differential Diagnosis:

    • Aseptic flexor synovitis (negative bacterial cultures).

    • Cellulitis (typically exhibits little or no pain with active range of motion).

Treatment for Flexor Tendon Sheath Infections

  • Utilize IV antibiotics with reevaluation in 12-24 hours.

  • If responsive, continue antibiotics for an additional 24-72 hours, transitioning to oral antibiotics for 7-14 days.

  • Surgical Option:

    • Necessary if unresponsive to antibiotics, particularly in cases exhibiting purulent drainage.

  • Red Flags:

    • Obvious septic tenosynovitis and lack of response to treatment warrant surgical intervention.

Animal Bites

  • Epidemiology: Approximately 3 million people experience bites yearly. Commonly found on the fingers of children’s dominant hands; dog bites constitute 90% of animal bites; cat bites make up approximately 5%.

  • Risk of Infection:

    • Dog bites: 5-10% risk of infection.

    • Cat bites: 30-50% risk of infection.

  • Causative Organisms:

    • Pasteurella multicida, along with Staphylococcus aureus, and various anaerobes (Fusobacterium and Bacteroides).

  • Rabies Transmission: 90% of rabies cases are transmitted by wild animals.

Signs & Symptoms of Animal Bites

  • Presenting symptoms include pain, puncture/laceration, and swelling and erythema that suggest infection.

  • Cellulitis and lymphadenopathy may also occur.

  • Classification: provoked vs. non-provoked bites. Rabid animals must be observed for 10 days for signs of rabies.

Physical Examination for Animal Bites

  • Assess the wound for jagged edges, swelling, and redness.

  • Purulent drainage if the wound is more than 10-12 hours old.

  • Red streaks on the skin indicate lymphangitis.

  • Examine sensation and tendon function, as well as lymph nodes in the elbow and axillary regions.

Labs/Diagnostics for Animal Bites

  • Obtain plain film imaging (AP, lateral & oblique) to rule out foreign bodies, such as dental fragments from the animal.

  • Perform wound swabs for Gram stain, including aerobic and anaerobic cultures.

Treatment for Animal Bites

  • Reminder: Tetanus shot is necessary.

  • Irrigation: Utilize copious normal saline (500-1000mL).

  • Oral Antibiotic Treatment: Augmentin (875 mg) BID for 7-10 days.

  • Primary Suturing:

    • Debated; advised only for clean wounds.

    • Can consider using a Penrose drain for promoting healing.

    • Generally, wounds should be managed openly and allowed to heal by secondary intention.

  • Doxycycline: May be an option for patients with penicillin allergy (not advised for pediatric population).

  • Rabies Considerations:

    • Contact health departments or animal control if rabies is suspected.

Human Bite Wounds

  • Types: Result from either direct bites or from a clenched fist injury.

  • Bacterial Concentration: They typically contain a greater concentration of bacteria than animal bites. Includes:

    • Anaerobic species

    • Eikenella corrodens

    • Alpha-haemolytic streptococci

    • Staphylococcus aureus.

  • Symptoms:

    • History of injury/laceration.

    • Warmth, swelling, pain, and purulent discharge, indicating possible infection.

    • Lack of flexion or extension may suggest tendon damage; loss of sensation may indicate nerve injury.

Physical Examination of Human Bite Wounds

  • Measure and document the extent of the laceration.

  • Note the location and severity of swelling, erythema, and discharge.

  • Assess flexor and extensor tendon function, and check for signs of ascending infection.

  • Look for lymphatic streaks and epitrochlear node involvement.

Diagnostic Tests for Human Bite Wounds

  • Obtain PA, lateral, and oblique radiographs of the hand.

  • Conduct aerobic and anaerobic cultures from the wound.

  • Initial white blood cell count (WBC) can serve as a baseline; however, it may appear normal if assessed acutely.

Treatment for Human Bite Wounds

  • Reminder: Ensure patient receives a Tetanus shot.

  • Outpatient Treatment: Feasible if joint integrity remains intact without bone or tendon injuries, and the patient seeks treatment within 8 hours.

  • Wound Anesthesia: Utilize 1% plain Lidocaine.

  • Debridement: Clean and debride skin edges and any necrotic tissue.

  • Examine the Extensor Mechanism: Over the MCP joint for any potential ligament/tendon damage.

  • Wound Exploration: Required with finger flexed and extended.

  • Irrigation: Copiously rinse the wound with saline and antibiotic solutions.

  • Immobilization: Implement a dorsal plantar splint in a functional hand position.

  • Antibiotic Regimen: Initiate with penicillin and a first-generation cephalosporin; if allergic to penicillin, consider Doxycycline.

Clenched Fist Injuries

  • Commonality: Typically present over the 5th MCP joint.

  • Mechanism: Often results from punching injury; the dorsal aspect of a closed fist hits opposing teeth, leading to laceration and possible avulsion fractures.

  • Considerations: These injuries can be easily overlooked.

  • Imaging Review: Radiographs should be closely examined for small osteochondral fragments.

  • Management:

    • Refrain from suturing these wounds closed—extensions proximally and distally may be necessary to appreciate the full extent of the injury.

    • Consult orthopedic specialists is advised.

Human/Animal Bite Wounds Follow-Up

  • Reevaluation Protocol: Advise patients to return within 24 hours for rechecks due to high infection risk.

  • Cleanse and Dressings: Ensure the wound is cleansed, and dressings are changed properly.

  • Wound Healing Management: Allow wounds to heal by secondary intention.

  • Non-healing Wounds: In cases of poor healing, consider urgent surgical debridement and IV antibiotics. Referral to surgery may be indicated if necessary.

Osteoarthritis of Hand and Wrist

Overview

  • Terminology: Also referred to as Degenerative Joint Disease (DJD) or Osteoarthritis (OA).

  • Main Causes:

    • Primary: Osteoarthritis and Secondary DJD.

    • Patients with Rheumatoid Arthritis (RA) may exhibit boggy joints, deformities, and joint instability, with articular cartilage destruction affecting tendons.

Characteristics of Osteoarthritis vs. Rheumatoid Arthritis

  • OA:

    • Most commonly affects DIP and PIP joints.

    • Patients experience greater pain on palpation.

  • RA:

    • Wrist and metacarpophalangeal (MCP) joints are most commonly affected.

    • Patients report increased pain in the morning and after prolonged activities.

    • Common to observe CMC OA, which presents as pain at the base of the thumb.

Arthritis of the Wrist

  • Common Causes: Previous trauma or RA.

  • Symptoms:

    • Swelling, tenderness, restricted range of motion (ROM), and impaired hand function, including radial deviation of the wrist and ulnar deviation of the fingers.

  • Physical Exam Findings:

    • Swelling, warmth, limited ROM, and pain on palpation localized to the radiocarpal joint.

    • RA patients typically show MCP involvement with wrist and finger deformities.

Diagnostic Tests for Arthritis

  • Imaging: PA and lateral X-rays.

  • Findings:

    • Primary/Secondary OA: Can show features such as subchondral sclerosis, joint space narrowing, spur formation, and erosions.

    • Gout: Early findings can indicate calcification of the triangular fibrocartilage complex (also referred to as Pseudogout).

  • Laboratory Tests Include:

    • ESR, rheumatoid factor (RA), antinuclear antibody (ANA), and uric acid levels.

Differential Diagnosis for Arthritis

  • Consider conditions like septic arthritis of the wrist (acute onset, severe pain, and limited ROM indicating infection).

  • Tenosynovitis (normal X-ray findings, localized swelling).

  • Treatment Options: Depend on arthritis type:

    • Immobilization splints

    • Corticosteroid injections (provided no infections exist)

    • Surgical interventions to improve stability and function.

Orthopaedic Pearls

  • Fracture Awareness: Always distinguish if a fracture is open before consulting orthopedics and examine the patient thoroughly.

  • Imaging Requirements: Keep plain X-rays handy; they are often necessary despite other imaging modalities.

  • Splinting: Proper padding is crucial for both patients and consultants.

  • Surgery Communication: Avoid making definitive statements about the need for surgery unless previously discussed with a surgeon.

  • Wound Management: Never suture any bite wound or suspected infection; keep wounds open and dress appropriately.

  • Culture Protocol: If a musculoskeletal infection is suspected (e.g., septic arthritis), avoid antibiotics until appropriate cultures are taken to prevent sterile cultures and inappropriate broad-spectrum antibiotic application.