Deep Space Infections

The hand offers numerous compartments in which infections may propagate and migrate. The volar surface of the hand encompasses many potential spaces that may become infected by direct inoculation or spread from surrounding structures. These include the thenar space, the midpalmer space, the radial bursa, and the ulna bursar (Fig 2.Z.Z.-2 and Fig.,2ZZ:3).

Palmar Spaces

FIG. 277-2. Anatomy. Flexor tendon infections may travel quickly along established anatomic planes and spread quickly to the ulnar and radial bursae.

Deep Palmar Space

FIG. 277-3. Deep palmar spaces. The midpalmar and thenar spaces are deep in the structures of the hand. The proximity to vital structures necessitates an aggressive management course including parenteral antibiotics and referral to a hand surgeon for drainage.

The volar aspect of the hand is covered by the tough and relatively fixed tissues of the palm; the veins and lymphatics course through the softer tissues on the dorsum of the hand; thus, regardless of the precise anatomic site of infection or inflammation, the dorsum of the hand always will swell whenever there is an inflammatory process. For this reason, a deep space infection initially may be misdiagnosed as a cellulitis over the dorsum of the hand if the practitioner does not obtain a thorough history and conduct a complete examination including palpation of the volar surface of the hand to elicit tenderness, induration, or fluctuance. Since these compartments are contiguous with the flexor tendons of the hand, range of motion of the digits often produces significant pain for the patient.

Occasionally, infections will arise in the web space. These "collar button" abscesses present with pain and swelling of the web space causing separation of the affected digits. Examination reveals induration or fluctuance in the dorsal and/or volar web space along with erythema, warmth, and tenderness. S. aureus and Streptococcus species are the most common organisms isolated.9!0

The emergency physician should initiate parenteral antibiotics (see T.ab!e...2.7Z-.l), and the hand should be immobilized and elevated. The patient likely will require analgesia while in the ED. Emergent evaluation by a hand surgeon is required because drainage of the infection should be undertaken in the operating room.

The most common "human bite" infection of the hand is actually the result of a patient striking another individual's teeth with a clenched fist. Because of the force associated with the contact and the penetrating nature of the human incisor, these infections tend to occur on multiple planes, and infection spreads rapidly to adjacent compartments. Skin, extensor tendons, joint space, bone, and surrounding deep spaces often are involved because the inoculum of saliva may traverse all these structures.

The physical examination should document the extent of the infection. Hand x-rays are indicated because closed-fist injuries are often associated with fractures. Since most of these wounds are open, a Gram stain and culture with sensitivities should be obtained for both aerobic and anaerobic bacteria.

The most common organisms reflect the natural flora of the mouth and include Streptococcus species, S. aureus, anaerobes, E. corrodens, and Neisseria species.58 Antibiotics should be initiated immediately (see Table .277.1,1). The wound should be cleansed, irrigated, and left open. The hand should be immobilized in the position of function and elevated. Disposition should be arranged in consultation with the hand surgeon.

A paronychia is an infection of the lateral nail fold or paronychium (Greek: para, "beside" + Greek: onyx, "nail"). Occasionally this may extend to the cuticle or eponychium (Greek: epi, "upon" + onyx). These common conditions are usually caused by minor trauma such as nail biting, manicures, or hang nails. The infection starts as a small area of induration that may be erythematous and tender.4

Most paronychia contain both aerobic and anaerobic bacteria. S. aureus and Streptococcus species are the most common aerobic bacteria cultured from these abscesses.7 Chronic peronychium may occur, particularly in patients who are immunocompromised. Atypical bacterial or fungal infections such as C. albicans have been identified in these cases.

If no fluctuance is identified, the paronychia may be treated with warm soaks, elevation, and antibiotics (see .T.ab.le...2..7.7.-1). Early intervention may prevent the need for surgical drainage. 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 paronychium or epionychium with a flat probe or no. 11 blade ( Fig, 277-4). This procedure sometimes can be performed without placing a digital block or providing analgesia.

FIG. 277-4. Paronychia. A. The eponychial fold is elevated using a flat probe or no. 11 blade in order to allow the wound to drain. B. Alternately, a no. 11 blade may be used to incise the area of greatest fluctuation directly into the epionychium. The wound may then be gently probed with a small clamp to ensure drainage.

More extensive infections that do not communicate directly with the nail fold may require incision directly into the area of greatest fluctuance. A digital block should be performed using lidocaine or bupivicaine prior to these more invasive procedures. Severe infections with pus beneath the nail require removal of a portion of the lateral or proximal nail to ensure adequate drainage.9 Rarely, a free-floating nail will be encountered on a bed of pus, necessitating removal of the entire nail.

Following incision and drainage, the patient should be instructed to keep the hand elevated and immobilized. Warm soaks may be initiated to keep the wound open and clean. The patient should be scheduled for reevaluation in 24 to 48 h. If significant cellulitis is present, a short course of antibiotics should be prescribed.

A felon is a subcutaneous pyogenic infection of the pulp space of the distal finger or thumb. The septa of the finger pad produce multiple individual compartments and confine the infection under pressure. The patient presents with marked throbbing pain and a red, tense distal pulp space. Infection typically begins with minor trauma to the dermis overlying the finger pad. With time, the bacterial infection gradually spreads between septa forming multiple compartmentalized abscesses. Left untreated, the infection may spread to the flexor tendon sheath and the interphalangeal joints, or eventually, osteomyelitis may develop.

S. aureus is the most common organism; however, Streptococcus species, anaerobes, and gram-negative organisms are encountered frequently. A Gram stain and culture should be obtained because these infections may be difficult to eradicate, and chronic infections may be caused by atypical organisms. 14 If osteomyelitis has developed, positive identification of the offending organism is necessary because long-term antibiotic therapy will be indicated.

If the finger pad is swollen and tense, or if there is any palpable fluctuance, drainage must be undertaken for healing to begin. A digital block must be performed because the procedure would be extremely painful without adequate anesthesia. A long-acting anesthetic such as bupivacaine should be used because postoperative discomfort is considerable. Most felons can be drained adequately with a limited incision and drainage procedure. A unilateral longitudinal approach is the most frequently used technique because it spares the sensate volar pad and achieves adequate drainage (see Fig, 2,7,7:5,A).

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