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Hand Infections
Hand infections
can cause severe problems that persist even after the infection has resolved,
such as stiffness, loss of strength, and even loss of tissues such as
skin, nerve and even bone. Thus early and aggressive treatment of hand
infections is essential. When seen early, some types of infection can
be treated with antibiotics and local rest and soaking. However many
infections begin to cause severe problems, even after a day or two, if
not treated with antibiotics, surgical drainage, and removal of infected
tissues. Any drainage or pus should be sent for laboratory testing to
determine the type of bacteria causing the infection and the appropriate
antibiotic for treatment.
A paronychia is an infection of the cuticle area
around the fingernail (see Figure 1). Acute paronychia is caused by bacteria,
and presents with redness, swelling, pain, and later with pus. Early
cases may be treated with soaks and antibiotics, but if pus is seen or
suspected, drainage by lifting the cuticle and/or nail, or lancing the
area, is required also. Chronic paronychia is caused by fungus, and the
cuticle area becomes just mildly red and swollen, with scant or no drainage
and mild tenderness. It occurs in people whose hands are frequently wet,
such as bartenders. It may be treated with special medication and reduction
or elimination of the constant exposure to moisture, which promotes this
fungal infection. On occasion, surgery is needed to remove infected tissue.
It is commonly mistaken for a bacterial infection. Prolonged treatment
is common with chronic paronychia.
A more serious and usually more painful, throbbing
infection, called “felon”,
occurs in the closed space of the fatty tissues of the finger tip and
pulp (see Figure 2).This usually requires surgical drainage and antibiotics.
If not treated early, destruction of the soft tissues and even bone can
occur.
Herpetic whitlow is a viral infection of
the hand, usually on the fingers, caused by a herpes virus. This is more
commonly seen in healthcare workers whose hands are exposed to the saliva
of patients carrying herpes. The condition, characterized by small, swollen,
painful blood tinged blisters, and sometimes numbness, is typically treated
conservatively and typically resolves in several weeks without many after-effects.
A wound in or near a joint,
or a draining cyst from an arthritic joint can cause a severe infection
of the joint, septic arthritis. In just a couple of days, the joint can
be destroyed by the bacteria eroding the cartilage surface of the joint.
Surgical drainage is required, in addition to antibiotics. If this treatment
is delayed, infection of the bone can occur, a complication that is called
osteomyelitis. It typically requires one or more operations to remove
infected tissue and many patients require weeks of intravenous antibiotics.
There are spaces in between the different
layers of structures in the hand which can become infected, even from
a small puncture wound. These may affect the thumb area (thenar space),
the palm (deep palmar space) or even the web area between the bases of
fingers (collar-button or web space abscess). These require surgical
drainage, and they have potential to spread to other areas, even to the
wrist and forearm.
If a small laceration or puncture
wound occurs over the middle of a finger, especially near a joint on
the palm side, an infection of the flexor tendon can occur. These can
often cause severe stiffness, even destruction and rupture of the tendon.
These present acutely with stiffness of the finger in a slightly bent
posture, diffuse swelling and redness of the finger, tenderness on the
palm side of the finger, and severe aggravation of pain with attempts
to straighten the finger (see Figure 3). This infection requires immediate
surgical drainage of the tendon sheath and antibiotics.
In rare instances, a tendon
sheath infection can be caused by an “atypical
mycobacterium.” These develop gradually and may be associated with
swelling and stiffness without much pain or redness. This type of infection
is treated with special antibiotics for several months. Surgical removal
of the infected lining of the tendons may also be necessary. Residual
stiffness is common, despite treatment. Such infections may involve other
soft tissues as well. Mycobacterium marinum is a common form and typically
develops after puncture wounds from fish spines, or contamination of
a simple wound or abrasion from stagnant water (in nature or from aquariums).
Identification of the organism can be difficult. Patients with impaired
immune systems (AIDS patients, cancer patients) are more susceptible
to atypical mycobacterial infections.
Infections from bites, from
humans or animals, are typically associated with several bacteria. Although
Streptococcus and Staphylococcus can be involved (driven in from the
skin by a tooth), other organisms common to the mouth may be seen and
typically require other or additional antibiotics. Eikenella corrodens
is often seen with human bite injuries and Pasteurella multocida is seen
with dog and especially cat bite wounds. Wounds frequently are not closed
after treatment so that any infection can drain out, and deep structures
such as joints may be involved. Surgical trimming of infected/crushed
tissue is often required. Rabies infection from an infected animal may
be serious, even fatal. Treatment is associated with risk. Fortunately,
the reported cases of rabies in humans are rare, and the incidence of
rabies is small in domestic animals, most cases coming from bites from
wild animals.
Acute paronychia
Felon
Flexor tendon sheath infection
© 2007 American Society for Surgery of the Hand
Developed by the ASSH Public Education Committee
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