Common Hand Injuries

Common Hand Infections

Braemar Hospital GPCME

1 November 2014

Waikato Hospital

Tristram Clinic, 200 Collingwood Street, Hamilton

P 07 838 1035 F 07 838 2032 E appts@tristramclinic.co.nz

Tauranga Hospital

Da Vinci Clinic, 727 Cameron Road, Tauranga

P 07 578 5350 F 07 578 5354 E brandon@davinciclinic.co.nz

Overview

• Common Hand Injuries

• Nail and pulp

• Distal phalanx

fractures

• Metacarpal fractures

• Common Hand Infections

• Nail and pulp

• Tendons and deep palm

• Bites

General Principles

General Principles

• Hands are resistant to infection - is the patient immunosuppressed?

• Oedema – HANDS SWELL!!

• Drainage of collections

• Cultures

• Immobilisation in safe position• Elevation• Tetanus• Antibiotics

Acute Paronychia

• Commonest infection in hand

• Infection of nail fold

• Edge of nail fold red and tender

• Staph Aureus commonly

Paronychia Treatment• Non surgical in early stages

• Cover staph aureus eg Flucloxicillin

• Moderate cases

• Ring Block

• Elevate nail fold off the nail plate

• Preserve the nail

• Severe Cases or any case with pus under the nail

• Ring block

• Remove part or all of the nail

• Incision parallel to the epoychium

Chronic Paronychia• Chronic maceration and obstruction

of fold

• Wet work + diabetics

• Scrapings, culture

• Candida albicans

• Topical steroids and anti fungals

• Diligent finger hygiene

• Trial of nail preservation

Chronic Paronychia

• Recurrent or resistant chronic paronychia

• Nail plate removal

• Topical and oral antifungal treatment

• Eponychial marsupialisation (Keyser and Eaton)-epithelialsition

Felon

• Subcutaneous abscess in

distal pulp of finger or

thumb

• Why are felons so painful?

• What are the common

mechanisms?

• What bacteria cause

felon?

Felon Treatment• Surgical drainage

• Ring block

• Incision of lateral aspect of

the pulp

• Parallel to the nail

• Mid axial line

• Never a “fish mouth”

Suppurative flexor tenosynovitis

• Penetrating injury

• Painful

• Red

• Swollen finger

• Pain with passive stretch

• Whole finger redness

Tendon Sheath Infection

Suppurative Tenosynovitis

• Tendon sheath is a closed

compartment

• Relatively immune

protected area

• Untreated infection can

destroy the tendon within

hours

Flexor Sheath

• Mid distal phalanx to

distal palmar crease

• May connect to adjacent

finger’s sheath

• May connect to carpal

tunnel

Kanaval’s Signs of

Tenosynovitis

• Partially flexed finger• Tenderness over flexor tendon sheath

• Differentiates tendon sheath infection vs. septic joint

• Pain with passive extension• 4th ADDED LATER Fuisiform swelling of finger

• Allen B. Kanaval, Prof. Of Surg. NorthWestern Univ. Chicago 1912• Mortality in 1912 from hand infection with ascending lymphangitis

was upto 30%

Tenosynovitis

• Treatment• Surgical drainage – open and irrigate

• Elevation

• Splinting

• I.V. Abs - Flucloxicillin

• Complications

• Necrosis of tendon

• Extension to forearm

• Median nerve compression

• Septic shock

Deep potential space infections

• Web space

• Mid-palmar space

• Thenar space

• Space of Parona

Web space abscess

• Abscesses may form in the

loose tissue of the webspaces

and discharge volarly, dorsally

or both

• A collar button abscess

describes two pockets of pus

connected by a narrow isthmus

Palmar Space Infections• Anatomy mid palmar and thenar spaces

Bites

• Human bite

• Dog bite

• Cat bite

Human bite

• Crush

• Abrasion

• Bruising

• Cellulitis

• Punch = “fight bite”

• Unreliable history

• Suspect deep injury

Human bite

• Wide range of bacteria

• Aerobic and anaerobic

• Most common are

• Gram positive cocci

• Eikenella corrodens – Gram -ve

bacillis

• Sensitive to beta lactam antibiotics

• Eg Amoxicillin / Clavulonic acid

• Second line

• Cotrimoxazole + Metronidazole

• Clindamycin

Cat bite

• Sharp

• Puncture wounds

• Most common

• Gram Positive Cocci

• Pasturella maltocida• Gram negative

• Sensitive to Amoxicillin

• Irrigate

• Dress don't suture

Dog bite

• 1 bite per 50 dogs per year in NZ

• Crushing

• Tearing injuries

• Tissue loss

• Fractures

• Gram positive cocci

Animal Bites

• Penetrating innoculum

• Look for teeth on Xrays

• Excise edges of wounds and clean

• Cats – Pasturella Multocida

• Augmentin recommended

Farm yard infections

• Increased anaerobes

• Clostridium perfringens

• Benzyl-Penicillin or

Metronidazole

Magic Words• Collection requiring drainage

• Suspected tenosynovitis

• Diabetic

• Failed trial of oral antibiotics

• Tissue loss

• Heavily contaminated

• Human bite

Common Hand Injuries

Nail and pulp injuries

• Subungal haematoma

• Nail bed laceration

• Finger tip amputation or near amputation

Nail and finger tip anatomy

Subungal haematoma

• Crush injury

• Painful

• Treatment?

• Investigations?

• Referral?

Nail bed laceration

• Crush injuries +/- underlying

fractures

• Split periosteum exposes bone

/ fracture

• Suspect growth plate fractures

in children

• Toddlers

• Siblings

• Doors

Nail bed laceration• Lacerations are repaired with dissolving

sutures (vicryl rapid)

• Nail is removed for access to nail bed

• Lacerations across the nail fold are more

complex

• Abrasions heal by secondary intention

• Nail bed scarring may lead to splitting or

separation of the nail

• Early nail separation can be treated with

nail bed grafts from toes

Finger tip amputation

Classification

Principles

• Define the defect

• Replace like with like

• Maintain length

• Skeletal stability

• Durable padded cover

• Restore sensation

• Early mobilisation

• Expeditious, simple & reliable

• Cosmesis

• Tailored to the patient

Reconstructions

• Primary closure / terminalisation

• Secondary intention - Dressings

• Grafts

• Local flaps• Homodigital

• Heterodigital

• Distal flaps

What can be dressed?

• 1/3 of the pulp = size of nail

• No exposed bone

• No Fracture

• Dress with semi-permeable

dressings

• eg IV3000

• Change as needed 2-3 days

Atasoy flap, 1970

Cross finger flap, 1951

Distal phalanx fractures

• A fracture is a soft tissue injury associated with

disruption of the bone

Neck of the distal phalanx

Tuft fracture

Fracture disrupting the

extensor insertion

Fracture disrupting the flexor

insertion

Metacarpal Fractures

Not all fractures need fixation

Thumb metacarpal

• Intrinsically unstable

• Isolated from other supporting bones

• Fractures of the base (Bennett’s, Rolando’s) involve

the CMC joint and the APL tendon

• Require anatomic reduction and immobilisation

• Frequently require fixation to immobilise

Finger Metacarpals

• Intrinsically stable

• Supported by adjacent bones and intrinsic muscles

• Length and alignment needs to be adequate to allow

a natural cascade of the fingers

• A moderate degree of flexion at the fracture site is

permissible while retaining good hand function

• Rotation is an indication for reduction

Degree of flexion

• Index metacarpal: 5-10 degrees

• Middle metacarpal: 10-20 degrees

• Ring metacarpal: 20-30 degrees

• Little metacarpal: 35-40 degrees

Indications for intervention

• Compound Fractures

• Fractures involving the joint

• Any rotation causing fingers to cross over

• Multiple metacarpal fractures

• Severe flexion

• Moderate flexion where dorsal hand and knuckle are

deformed

Managing a metacarpal

• X-ray to confirm fracture orientation

• Haematoma block 10mL of 1% lignocaine or 0.75% ropivocaine

• Manipulation and “ulnar gutter spint”

• MCPJ flexion

• IPJ extension

• Confirm reduction

• Rpt X-rays in 1 week

Magic Words• Compound

• Tissue loss

• Avulsion

• Amputation

• Not perfused

• Rotated

• Unstable

Waikato Hospital

Tristram Clinic, 200 Collingwood Street, Hamilton

P 07 838 1035 F 07 838 2032 E appts@tristramclinic.co.nz

Tauranga Hospital

Da Vinci Clinic, 727 Cameron Road, Tauranga

P 07 578 5350 F 07 578 5354 E brandon@davinciclinic.co.nz