Download Hand examination and hand infection

Hand examination and hand infection
Hand:
Mechanical device with receptors can produce powerful delicate and fine
movements. The requirement for the hand function:
1. Good skin coverage with intact sensation.
2. Supple joints and mobile fingers.
3. Pain free movements and with good tendon excursion.
History:
The patient age, hand dominance, occupation and history of prior upper
extremities problem are obtained.
For traumatic injury: The time, mechanism and circumstances (e.g. work
related, contamination) of injury are obtained. Also should know the
position of the limb during injury (e.g. fall on outstretched hand, hand open
or grasping).
For nontrumatic conditions: Detail about onset and course, whether there is
impairment in sensation, or loss of function, also ask about pain and
swelling.
Physical examination:
Look:
Skin: For any cuts, haematoma, swelling, bruise, nail,also look for tight
Bands in palm leading up to fingers (duputyren contracture).
Soft tissues: Check for thenar and hypothenar wasting also check for
Wasting in cleft between fingers dorsally (damage to
Ulnar nerve or T1).
Bone: Look for swan neck deformity (have extension in middle IP joint
With flexion of distal IP joint).
Look for Boutonniere deformity (have extension at distal IP joint
With flexion at middle IP joint).
Also look for Heberden nodule over the DIP joint dorsally which
Associated with osteoarthritis.
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Feel:
Skin: feel for loss sensation or altered sensation by (cotton wick, pin
Test) along median, ulnar, radial nerve distribution.
Soft tissues: check for capillary filling in the fingers and check both
Radial and ulnar pulses. Also feel for wasting of first
Dorsal interosseous on radial side of the first
Metacarpal.
Bone: feel for any swelling, tenderness.
Move:
Active: test roll up of fingers from full extension to full flexion, test
Flexion of MCP joint in isolation while keeping PIP joint and
DIP joint extended.this test patient ability to intrinsic muscles
Movement. Also test abduction and adduction of fingers.
Passive: Passively move the joints to see the range of movement,
Pain in movement, and unstable joints.
Investigation:
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Plain x-ray
E.M.G
Ultrasound
Angiography
M.R.I
CT\SCAN
General management:
Trauma
Infection →swelling→ligament adhesion and→loss of function
Surgery
contracture
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1- Rest: resting an infecting part minimizes the opening of tissue
plane along which it can spread and the breaking down of barriers
which is important for wall off the infection.
2-Splinting :when we need to immobilize hand it should be putting
in (safe position) this keep ligament under maximum stretch to
prevent their shortening and subsequent restriction of joint
mobility.
Safe position: IP joint extension, MCP joint flexion and palmer
abduction of thumb and slight wrist extension
3- Elevation of hand above the level of the heart so encouraging venous and
lymphatic return and thus prevented swelling. which is minimizes edema
due to the inflammatory reaction and poor muscular activity which is due to
pain and therapeutic rest.
The point of reference for elevation of the part is its relation to right atrium
of heart.
4- heat application: the application of heat increase the delivery of
inflammatory cells to affected area by vasodiltation, and laso improve
patient comfort.
Moist heat more effective than dry heat. Frequent seperated application are
recommended rather than attempting to do it continuously.
5- Splintage-posture: when we need to immobilize hand it should be putting
in (safe position) this keep ligament under maximum stretch to prevent their
shortening and subsequent restriction of joint mobility.
Safe position: IPjoint extension, MCP joint flexion and palmer
abduction of thumb and slight wrist extension.
6- movement and rehabilitation :should done for non injured Finger from
time of injury and for injured fingers as soon as because prolonged
immobilization can lead to stiffness of small joints, immobilization should
be maintained where essential for minimal time while continued movement
of other parts is encourages.
7- antibiotics: in all cases , initial antibiotic selection has to be on a
(best guess). The majority of hand infection are due to
staphylococcal and streptococcal bacteria, with anaerobic bacteria
being relatively rare. Therefore, it is recommended that for
ordinary caese , a penicillinase resistance antibiotic such as 1st
generation cephalosporin, which may combined with antistaph
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penicillin, be used. Antibiotic change later according to result of
culture and sensivity test.
8- surgical drainage: any abscess or necrotic tissues that can be
positively identified, it should be surgically drained and specimen
for bacterial studies should be taken.
Hand infection:
may involved skin, subcutaneous tissue, tendon sheath, joints and
bone and may be caused by wide of vraiety of pathogens, including
viruses,bacterai,mycobacteria and fungi.
Three major factors contribute to development of infection in
hand:
1-the infecting organism
2-the anatomic location of the infected space.
3-systemic and local host defense factors
Specific infection:
1. Cellulitis and lymphangitis: all hand infection begins as celulitis, .
cellulitis is non-supporative superficial infection of skin. there is poor
localization in addition to the cardinal sign of inflammation i.e.
redness,hotness,swollen,pain and tendrness.usaully caused by B hemolytic
streptococci, staphylococci and c.perfringens.tissue destruction,gangene and
ulceration may follow ,which are caused by release of protease.
Systemic sign and symptoms like fever,chill,tachycardia follow the realese
of exotoxine and cytokines into circulation.
Cellulitis is usually located at the point of injury and subsequent tissue
infection.
Because gram positive organism are typically responsible, first generation
cephalosporin or pencillin is appropriate.
Lymphangitis is part of a similar process and present in painful red streak in
affected lymphatic usually accompanied by painful lymph node groups in
the related drainage area.
The vast majority of cases will respond to oral antibiotics, rest, warm soaks
and elevation.
Because gram positive organism are typically responsible, first generation
cephalosporin or antistaph penicillin is appropriate e.g. flucloxacillin.
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2. Acute paronychia: this is the most common infection of the hand, is
infection of the soft tissues alongside the nail plate. this is typically result
from inoculation of bacterium between the nail and surrounding tissues,
often as consequence of relative minor trauma such as nail biting, puncture
wound, foreign body.
S.aureus is the most common isolate, but anaerobes are frequently present
and attributed to contamination of the wound with oral secretion. Usually
presented with pain, erythema and oedema of tissues surrounding the nail,
later on if no treated abscess may be formed.
An infection that involves the proximal nail and one lateral fold known as
eponychia
When the abscess dissects under the nail sulcus to the opposite lateral fold
know as run around abscess. Confined collection of pus can place presure on
germinal matrix, resulting in nail deformity
Treatment: if the paronychia diagnosed at an early stage before abscess
formed, oral antibiotics, warm soak, rest, and elevation may be sufficient
treatment.
-For abscess localized to one lateral fold , the fold can be elevated bluntly by
Freer elevator or blade can be used.
-For treatment of eponychia : two incision are made at the edge of nail fold,
the proximal nail is excised , and the fold is elevated and packed with guaze.
Rarely, the pus collection will elevated entire nail plate, which need at that
time removal of nail plate.
3. Chronic paronychia: : A paronychia may present as a chronic
process, with an indurated,erythematous eponychium (proximal nail fold)
and occasional drainage from the nail fold and longitudenal grrove in the
nail plate. This occurs more frequently in diabetic patients and in those with
frequent occupational exposure to a moist environment, such as food service
handlers with frequent immersion of the hands in water. Candida albicans is
the most common pathogen responsible.
Treatment: it may resolve if the hands are kept dry and the nail fold are
regularly dressed with antifungal e.g. clotrimazole.if no response, Removal
of a thickened , deformed nail plate may be improve the result.
If all are failed , eponychial marsupialization is done, where a crescentshaped portion of the skin overlying the proximal nail bed is excised , with
removal of all granulation tissues down to germinal matrix. The wound is
leave to healed by secondary intention.
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4. Flon: A felon is an abscess of the distal pulp of the thumb or finger.
Because of the unique anatomy of the pulp, with 15 to 20 longitudinal septa
anchoring the skin to the distal phalanx, the pulp is divided into multiple
closed compartments. Abscess formation within these small closed
compartments results in rapid development of swelling and throbbing pain.
The pain is usually worsened by dependency, and may keep the patient from
sleeping at night.
Felons typically present after a history of a puncture wound, thus
radiographs should be examined carefully for evidence of retained foreign
body.
The most common pathogen involved is S. aureus
Complications of untreated or inappropriately treated felon:
1-painful , unstable , insensate , unaesthetic scar.
2-acute flexor tenosynovitis
3-septic arthritis.
4-osteomylitites.
5-deep space infection.
6- amputation.
Treatment: Early felons may resolve with oral antibiotics, warm soaks,
rest, and elevation; however, any sign of fluctuance requires surgical
drainage.
A variety of incisions have been described for the drainage of felons.
If the abscess is pointing, the preferred approach is a longitudinal volar
incision through the tip of the abscess, and should not cross the DIP crease.
Alternatively, a longitudinal incision is made just dorsal to the midlateral
line, and may be extended around the tip of the finger in a “hockey stick”
fashion for extensive felons
5. Bacterail flexor tenosynovitis:
synovial sheath that surrounding index , middle and ring finger extended
from DIP to MCP. In thumb has a sheath from IPJ through a radial bursa
into the distal forearm. The little finger synovial sheath extended from DIP
to large ulnar bursa which surronded the FDS and FDP tendons of all four
digits from midpalm proximally to proximal margin of pronator quadratus.
In 80% there is interconnection between radial and ulnar bursa in palm.
Flexor tenosynovitis is a surgical emergency as the pressure and pus in
tendon sheath cause ischaemic necrosis of the tendon, leading to rupture. In
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lesser state the tendon rapidly adhere to its sheath result in permenant
stiffness. The cause is penetrating injury of flexor tendon at level of DIP and
PIP. The injury may be not noted by patient.
The ring , middle, and index finger are the most commonly affected, and S.
aureus is the most common isolate.
Kanavel signs: described the four cardinal signs of flexor tenosynovitis
that bear his name:
(a) fusiform swelling of the finger
(b) partially flexed posture of the digit
(c) tenderness over the entire flexor tendon sheath
(d) disproportionate pain on passive extension
The latter sign is the most constant and typically the first present in early
cases.
treatment:
Early cases of flexor tenosynovitis (i.e., less than 48 hours ) may respond to
conservative management, including intravenous antibiotics, rest, heat, and
elevation.
Failure to respond within 24 to 48 hours warrants immediate operative
intervention.
Less severe cases of flexor tenosynovitis may be treated with a limited
incision and catheter irrigation technique (close method). A transverse
incision is made
just distal to the distal flexion crease. A similar incision is made in the palm
over the proximal edge of the A-1 pulley The sheath is copiously irrigated
with sterile normal saline
For severe cases, zigzag fashion incision is made over the entire course
of the flexor sheath (open method). The wound is packed open, and is
loosely approximated when the infection has subsided. Early and aggressive
hand therapy is indicated for all cases.
6. Deep space infection: there are 5 potential spaces between hand
structures:
 Thenar space
 Midpalmer space
 Web space
 Thumb adductor
 Hypothenar
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Of these the thenar and midpalmer space are clinically the most important.
A penetration injury such as a splinter is often the inciting event in palmer
space infection and S.auerus is the most common pathogen.
All present with swollen hand, frog hand, very tender areas, restriction of
movement with generalized symptoms like malaise, fever.
Treatment: antibiotics, elevation, hot soack. if no response, drainage of
abscess according to site of infection, with special incision and irrigation.
For midpalmar space preferred to do curve longitudinal incision in the palm
with care to avoid injury to superficail palmar arch and digital vessels.
For thenar space infection combined dorsal and volar incision , slightly
curve longitudinal incision in dorsum of first web space, and separated
incision on thenar eminence parallel to thenar crease. Care to avoid injury to
palamr cutaneaous nerve and motor branch of median nerve
7. Bites: serious infection and subsequent loss of function can result from
animals or human bites.
Human bite is potentially serious because of virulence organism comprising
human oral flora. Human saliva may contained as many as 100 millon
microorganism per milliliter, with over 42 species. S. aureus and
Streptococcus viridans are the most common pathogens, also contained
anaerobic bacteria e.g. Bacteroides sp. and Eikenella corrodens. The most
common mechanism is striking a tooth with a clenched fist.
The wound is most commonly over the metacarpophalangeal joints, putting
the extensor mechanism and joint surfaces at risk of injury
Radiographs are mandatory, and may reveal a tooth fragment, fracture of the
metacarpal
head, or air in the joint.
Treatment:
All human bites to this region should be explored . The joint space should be
irrigated and wound edges debrided. Human bite wounds should not be
closed primarily, but in selected cases, large wounds may undergo secondary
closure after 7 to 10 days of dressing changes and antibiotics. Eikenella
corrodens is sensitive to penicillin and to clindamycine.
Animal bites: cause by domestic dog and cat ,these wound tend to be less
infected than human bite, but can cause substantial crush because of
powerful jaw of dog. Cat bites are usually small puncture wounds because
cat teeth are long and sharp.
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All animal bites should be thoroughly irrigated and joints explored when
potentially violated. The majority of acute dog bite wounds may be loosely
approximated after debriding the edges sharply.
Cat bites rarely require closing, but may be if needed.
Antibiotic coverage for animal bites should cover the mixed flora found in
animal saliva. This includes the gram-positive Staphylococcus and
Streptococcus spp., anaerobes such as Bacteroides sp., and Pasteurella
multocida, a small, gram-negative
coccus
8.Viral infection: most commonly caused by herpes simplex virus and
called herpetic whitlow and commonly seen in dental and medical personnel,
and in children .usually presented with intense pain and erythema and small
vesicular rash usually it self limited resolve in 3-4 weeks.
The distinction from felon is made primarily from the history. Herpetic
whitlow usually presents with a prodromal phase of 24 to 72 hours of
burning pain prior to the development of skin changes. This is followed by
erythema and swelling, then the formation of clear vesicles. The vesicles
may coalesce. The fluid within may become turbid, but not frankly purulent
without bacterial superinfection. The pulp of the affected digit is not tense as
in a felon.
The diagnosis may be confirmed by viral culture .
This process occurs over approximately 2 weeks and then resolves over the
next 7 to 10 days.
Treatment: supportive care,acyclovir oral or intavenous.
Incision and drainage of a whitlow will invariably lead to a worse outcome
than conservative management..
9. Mycobacterial infection: tuberculosis in the hand may involve the
tenosynovium, joints or bone. The most drastic is so called compound
palmer ganglion with synovial swelling both proximal and distal to
transverse ligament.
Diagnosis confirm with biopsy. Treatment is by synovectomy and prolong
anti T.B treatment.
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