3. Hand & Foot Infections.pdf

Infections of Hand & Foot Prof. U.Murali. Learning Objectives • Classify infections of hand. • Identify the tendon zones in hand. • Describe the general features, complications, investigative methods of hand infections. • Mention the principles involved in treating hand infections. • List the type...

Infections of Hand & Foot Prof. U.Murali. Learning Objectives • Classify infections of hand. • Identify the tendon zones in hand. • Describe the general features, complications, investigative methods of hand infections. • Mention the principles involved in treating hand infections. • List the types of foot infections and add a note on In-grow toenail. • Write about – Paronychia / Felon / Infection of spaces of hand. HAND INFECTIONS Introduction • Hand is a compact actively functioning unit due to its mechanical & sensory functions. {vascular, M, B & ligaments} • It is one of the most developed structures in the human evolution. • Infection may be due to minor injuries (or) blood borne. Surgical Anatomy - Hand • Superficial Fascia: > Palmaris Brevis > S. Trans. Metatarsal Ligament • Deep Fascia: • Flexor Retinaculum – fibrous band so as to bridge carpus to create a carpal tunnel. • Palmar Aponeurosis – It is a thickened modified deep fascia in the palm - apex pointing proximally & base distally - turn gets divided into four parts. • Fibrous digital sheaths. Muscles of Hand • Thenal muscles – APB, FPB, OP & AP. • Hypothenar – ADM, FDM, ODM & PB. • Lumbricals – 4 in no. – named from lateral to medial. • Palmar interossei – 4 • Dorsal interossei – 4 Surgical Anatomy - Hand • Blood Supply – Superficial palmar arch – formed by ulnar artery / Deep palmar arch – formed by radial artery. • Nerve supply – All muscles [15] in hand – Ulnar nerve / 5 muscles [APB, FPB, OP & 1ST & 2ND Lumbricals] – Median nerve. Spaces of the hand • Palmar Spaces – Pulp space - Mid-palmar space - Thenar space • Dorsal Spaces – D. Subcutaneous - D. Subaponeurotic • Space of Parona • Bursas – Radial Bursa - Ulnar Bursa Tendon Zones – Modified Verdan Zone • Zone 1 - One tendon only (FDP) from middle of middle phalanx distally. • Zone 2 - Two tendons (FDS & FDP) from MCP joints to middle of middle phalanx [critical zone]. • Zone 3 - Central palm (lumbricals). • Zone 4 - Tendons in the carpal tunnel. • Zone 5 - Tendons proximal to the carpal tunnel. Precipitating Causes • Diabetes • Immunosuppression • Trauma • HIV infection • Steroid therapy • Vascular diseases Common Organisms • Staph. aureus—commonest • Streptococcus • Gram–ve-E.coli,Kleb.,Pseud. • Occ. fungal infection & viral infection can occur General Features • Infection spreads faster in all areas. • Causes oedema over the dorsum of hand. It looks like frog hand. • Restricted movements of fingers and hand. Hook, pinch, grip, grasp are lost. • Severe pain and tenderness, with fever. • Tender palpable axillary lymph nodes are often present. Investigations • Pus for culture & sensitivity. • Blood sugar. • Urine sugar & ketone bodies. • X-ray of the part. General Principles • Position of rest • Elevation of hand - ↓oedema • Early recognition – Pus - I & D • Blood less field • After AB - trt – Physiotherapy Complications • Stiffness of digits and hand (ankylosis) • Deformity and disability • Bacteremia and septicemia • Osteomyelitis of bones • Suppurative arthritis of joints • Paralysis of median nerve Classification [I] Cut.& sub-cut.infections: • Paronychia • Pulp Space Infection (Felon) • Web Space Abscess [II] Fascial spaces infection: • Deep Space Infection i.e. mid palmar space, thenar space & Parona’s space. • [III] Inf. of the tendon with its synovial sheath “tenosynovitis”. • [IV] Inf. of the bone & joint “septic arthritis”. • [V] Miscellaneous infections. I-A. Paronychia – A/C • Most common hand infection. • Infection of the soft tissues surrounding the fingernail. • Minor injury - is the common cause. • Severe throbbing pain and tenderness with visible pus under the nail root. • The pus is drained by making an incision over the eponychium. I-B. Felon • A felon is an abscess of the distal pulp of the thumb (or) finger. [collar stud abscess] • Usually a minor injury – finger prick. • Infection results in edema and increased pressure within the closed compartment. • Drainage of terminal pulp space by an longitudinal deep incision. I-C. Web space Abscess • There are 4 triangular web spaces filled with fat between the dorsal and volar skin. • Begins beneath palmar callus – in laborer's. • Oedema of dorsum of hand + Max. tenderness is on the volar aspect. • ‘V’ sign—Separation of fingers. • Incisions – 1 dorsal and 1 palmar. • Web - not incised. II. Deep space Infection • These are infections in the potential deep spaces of the hand, i.e. Midpalmar space, Thenar space & Parona’s space. • Protects neuro-vascular structures & permits gliding of tendons within the hand. • Infections - may follow blood spread, penetrating injury (or) rupture of pus from a flexor tendon sheath. II-A. Thenar space Infection • It lies post. to the long flexor tendons to the index finger and in front of the adductor pollicis muscle. • Pain and swelling of thenar eminence and first web space. • Thumb is held abducted & flexed. • Combined dorsal and volar incisions. Avoid injury to branches of median nerve. II-B. Mid-palmar space Infection • It lies post. to the long flexor tendons to the middle, ring & little fingers. It lies in front of the interossei and the 3rd,4th & 5th metacarpal bone. • Loss of normal hand concavity with dorsal edema – “Frog’s hand”. Pain with movement of 3rd and 4th digits.[IJt – normal + painfree] • Either longitudinal (or) transverse approach for drainage. II-C. Parona space Infection • It is deep in the distal forearm between the PQ muscle & the FDP tendons. • This space is contiguous with the radial bursa, ulnar bursa and mid palmar space. • A flexor tendon sheath infection may extend proximally to involve the bursae and Parona’s space. • Swelling, tenderness, & occasionally fluctuance of the distal volar forearm. Digital flexion may be painful. Dorsal space Infections • Diffuse swelling – Dorsum of hand • Edema will be seen • Normal concavity – palm - retained • Digital extension – very painful • Treatment is similar to that recomm. for other infections III. Tenosynovitis • It is the bacterial inf. of flexor tendon sheaths. • It is the inflam. the fluid-filled sheath (called the synovium) that surrounds a tendon. • Common flexor synovial sheath (ulnar bursa) [FDP / FDS] • The synovial sheath of the tendon of flexor pollicis longus - FPL (radial bursa). • Both comm. with each other in 80% of cases. Tenosynovitis - cont. “Kanavel Sign” – > Finger in slight flexion > Fusiform swelling > Severe pain on extension. > Tenderness - tendon sheath • Treatment is similar to that recomm. for tendon infections: open (or) closed irrigation, leaving a drain in situ and antibiotic cover. FOOT INFECTIONS Callosity • It is a hard, thickened skin occurs as a protective measure seen in wider area usually over heel & heads of metatarsals. • A callosity protrudes outwards from the skin. • It is painless. It can be rubbed easily to create a sore. • It is usually left alone. Corn • It is localized area of thickening over a bony projections like heads of metatarsals. • It presses over the adjacent nerves causing pain. • 2 types – Hard / Soft corn. • It can get infected causing severe pain and tenderness with inability to walk. In grow Toenail (Onychocryptosis) • It is due to curling of the side of nail inwards, resulting in repeated irritation & infection of overhanging tissues in the nail fold. • Causes: Tight shoes; Improper cutting of nails. • It is common in great toe and is often bilateral. • Pain, swelling of margins of toe with GT & foul smelling discharge. • Trt - Zadik’s or Fowler’s operation. Key Points to Remember Do’s Don’ts Examine hand carefully Do not incise every infected digit Think of other diagnosis Do not make puncture incisions Wait for abscess to localize Do not injure digital vessels or nerves Place adequate depth and length of incisions Do not place incisions crossing the creases Immobilize, elevate the hand Do not close bite wounds Antibiotics & proper dressings Do not forget pus culture and sensitivity To Summarize • Surgical anatomy of hand & tendon zones of hand. • Precipitating causes & organisms causing hand infections. • General features, Investigations & Complications of hand infections. • General principles of treating hand infections. • Various types of hand infections & their treatment methods. • Foot infections – types & features. References Question Time • Classify infections of hand. List the types of foot infections. • Mention 4 general principles of treating hand infections. • Identify 4 general features & complications of hand infections. • State 4 differences between paronychia and felon. • Outline about deep space infections of hand. • Write a note on in-grow toe nail. • Name the components of “Kanavel Sign”. The most dangerous zone in hand injuries, according to Modified Verdan Zone System is – • a) Zone – I. • b) Zone – II. • c) Zone – III. • d) Zone – IV. The most dangerous zone in hand injuries, according to Modified Verdan Zone System is – • a) Zone – I. • b) Zone – II. • c) Zone – III. • d) Zone – IV. One of the following is true regarding callosity & corn foot – • a) Callosity is limited to the epidermal region. • b) Callosity is common in females. • c) Corn is of two types – Smooth & Irregular. • d) Corn never recurs after excision. One of the following is true regarding callosity & corn foot – • a) Callosity is limited to the epidermal region. • b) Callosity is common in females. • c) Corn is of two types – Smooth & Irregular. • d) Corn never recurs after excision. A 19-year-old student has sustained a cat bite to her dominant right index finger. She has a sausage-like flexed index finger, pain on extension of her involved finger, and tenderness in her palm. Which is the most likely diagnosis? • a. Palmar space infection. • b. Flexor sheath infection. • c. Paronychia. • d. Septic arthritis. A 19-year-old student has sustained a cat bite to her dominant right index finger. She has a sausage-like flexed index finger, pain on extension of her involved finger, and tenderness in her palm. Which is the most likely diagnosis? • a. Palmar space infection. • b. Flexor sheath infection. • c. Paronychia. • d. Septic arthritis. One of the following hand infections resembles that of Frog’s hand – • a) Dorsal space infection. • b) Thenar space infection. • c) Mid-palmar space infection. • d) Parona space infection. One of the following hand infections resembles that of Frog’s hand – • a) Dorsal space infection. • b) Thenar space infection. • c) Mid-palmar space infection. • d) Parona space infection. Which one of the following hand infections can result in collar-stud abscess? – • a) Apical subungal infection. • b) Web space infection. • c) Dorsal space infection. • d) Terminal pulp space infection. Which one of the following hand infections can result in collar-stud abscess? – • a) Apical subungal infection. • b) Web space infection. • c) Dorsal space infection. • d) Terminal pulp space infection. Surgeon should have – “A heart of lion / Eyes of a hawk & Hands of a woman”.