Mark W. Fourre
Flexor .Tenosynovitis Deep Space Infections infections. from .Closed-Fist „IniuEi.es Paronychia
Noninfectious.. lnflamm.atory..S.tates...of. .th.e..Mand GeneralPrincipies
Tendjnitis..and.. .Tenosynovitis Trigger.F.inger
Carpal Tunnel Syndrome
Dupuytren's. Contracture Chapter.. References
Patients with hand infections routinely use the emergency department (ED) as their initial site of care. It is important for the emergency physician to accurately diagnose and treat the infection because failure to do so will likely cause long-term morbidity and disability. The hand is one of the most elegant and complex features of the human body, and the emergency physician must understand the basic anatomy and functions of the hand in order to appropriately manage the patient.
Infection is most commonly introduced by an injury to the dermis. The infection initially may remain superficial, as a cellulitis, or localized, as a paronychia or felon. Left untreated, these infections ultimately will spread along anatomic planes or to adjacent compartments in the hand. Deeper injuries may directly seed underlying structures, giving rise to rapidly spreading infections such as seen with closed-fist injuries or cat bites. Rarely, hematogenous spread may be the source of hand infections.1
A directed history must be obtained to delineate a likely cause of the infection. Patients who present with systemic symptoms secondary to a hand infection are seriously ill, and parenteral antibiotics with inpatient management is indicated. A history of chronic illness or immunodeficiency must alert the physician to the possibility of atypical pathogens.23
Since hand infections tend to disseminate along anatomic compartments and planes, the physical examination should be directed at defining the anatomic limits of the infection. The examiner should document if the process involves the skin, subcutaneous tissues, fascial spaces, tendon, joint, or bone. 4 If deep structures of the hand are involved, emergent consultation with a hand specialist is indicated because treatment likely will involve inpatient care and drainage in the operating room.
With the exception of superficial cellulitis, hand infections are surgical problems that must be managed using accepted surgical principles. 5 First, if there is pus, drain it. Superficial and discrete infections, such as paronychia and felons, can be drained in the ED. All other infections involving deep structures in the hand should be treated in the operating room by a hand surgeon. Second, immobilize and elevate the extremity. This will rest the hand, reduce inflammation, avoid secondary injury, and limit anatomic extension of the infection. Immobilization is accomplished by applying a bulky hand dressing and splinting the hand in a position of function: the wrist at 15 to 30° of extension, the metacarpophalangeal (MCP) joints at 50 to 90° of flexion, and the interphalangeal (IP) joints at 5 to 15° of flexion ( Fig, 277-1). The hand may be elevated on pillows or suspended using stockinet. Third, broad-spectrum antibiotics should be initiated ( Table. ...2.7.7-1). Finally, serial examinations should be performed to ensure that an effective management plan has been instituted. If the patient is not admitted to the hospital, timely and appropriate follow-up must be arranged by the emergency physician.
FIG. 277-1. Positioning the hand during immobilization. Top position is used when splints are applied in fractures or severe sprains. Bottom position is position of function used when applying a soft bond dressing.
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