Hand and finger infections

Background

• Pts w/ systemic symptoms due to a hand infection are seriously ill; require inpatient management

Hand Cellulitis

Background

• Remove rings if infections are near the digits

Clinical Features

• Erythema, warmth, and edema
• Range of motion of digits, hand, and wrist should not be painful
  • Pain predicts extensive involvement and the need for inpatient management

Treatment

• Mild/moderate cellulitis
  • TMP/SMX DS 1-2 tab PO x 7-10d + (cephalexin 500mg PO QID x7-10d OR dicloxacillin 500mg PO QID x 7–10d
• Severe cellulitis
  • Vancomycin 1gm IV q12hr

Disposition

• Consider admission for:
  • Immunocompromised
  • Clinical toxicity
  • Evidence of deep-space involvement
  • Rapidly spreading infections

Flexor Tenosynovitis

Background

• Surgical emergency; flexor sheaths are contiguous w/ deep spaces of the hand
• Usually associated with penetrating trauma

Clinical Features

1. Percussion tenderness
   1. Tenderness over entire length of flexor tendon sheath
2. Uniform swelling
   1. Symmetric finger swelling along length of the tendon sheath
3. Pain w/ passive extension
4. Flexion posture
   1. Flexed posture of involved digit at rest to minimize pain

Management

1. Antibiotics
   1. Start immediately
   2. Vanco 1gm IV q12hr + (ampicillin-sulbactam 1.5gm IV q6h OR cefoxitin 2gm IV q8h OR piperacillin/tazobactam 3.375gm IV q6h)
2. Consult hand surgery in the ED

Deep Space Infection

Background

• Volar surface contains potential deep spaces that may become infected
• Dorsal aspect contains the veins and lymphatics; will always swell whenever there is an inflammatory process

Clinical Features

• Tenderness, induration, or fluctuance over volar aspect of hand
• Pain w/ range of motion of digits

Management

• Parenteral antibiotics
• Hand surgeon consult

Closed Fist Infection "Fight Bite"

Background

• Result of striking another individual's teeth with clenched fist
• Most commonly affects dorsal aspects of third, fourth, and fifth MCP joints
• Although may appear benign, significant morbidity can result from late presentation or inadequate initial management

Clinical Features

The physical examination should document the extent of the infection. Hand x-rays are indicated because closed fist injuries are often associated with fractures, or may contain tooth fragments. Infections are typically polymicrobial. The most common organisms reflect the natural flora of the mouth and include Streptococcus species (82%), S. aureus (57%), E. corrodens (32%), Fusobacterium (27%), Peptostreptococcus (14%), and Candida (3.6%) species. If infection is detected or examination suggests injury to the joint, joint capsule, tendons, or deep spaces, a hand surgeon should be consulted for open debridement and irrigation in the operating room. Administer parenteral antibiotics. Elevate the hand and immobilize it in the position of function. Prophylactic antibiotics should be initiated for all but the most superficial wounds caused by a clenched fist

Source

• Tintinalli