Orthopedic Surgery for Hand Infections Treatment & Management
- Author: Matthew B Klein, MD; Chief Editor: Harris Gellman, MD more...
Some early infections can be managed with antibiotics. For example, antibiotic treatment is appropriate for cellulitis, and oral antibiotics are usually the appropriate first line of treatment. However, persistent cellulitis or infections in immunocompromised patients should be treated with intravenous (IV) antibiotics until the cellulitis resolves. Then, completion of a course of oral antibiotics is appropriate.
If any signs of fluctuance or purulent wound drainage are present, incision and drainage is necessary. Furthermore, cellulitic infections that are unresponsive to antibiotics may require surgical exploration. Surgeons who undertake incision and drainage should be familiar with the anatomy of the hand, including the anatomy of the nail, the course of the digital neurovascular bundles, and the deep spaces of the palm. Furthermore, appropriate management requires close postoperative monitoring.
A few important guidelines assist in the management of hand infections. First, cellulitis must be treated with antibiotics. Most hand infections are caused by S aureus, and therefore, a first-generation cephalosporin (eg, cephalexin) is usually the first drug of choice. However, the potential exists for infections with different organisms.
In fact, an increase in the incidence of community-acquired (CA) methicillin-resistant S aureus (MRSA) infections has been reported.[19, 4, 5, 6, 20, 21, 22] In a retrospective review of 159 hand infection surgeries, Imahara and Friedrich found that 48 operations were performed for CA-MRSA, and IV drug use was found to be the only independent risk factor for CA-MRSA during that period; other factors were felon-type infection and prior hand infection.
Evolving resistance patterns in MRSA should be considered. In one study of MRSA hand infections, the organism was found to exhibit significantly increased resistance to clindamycin and levofloxacin; only sporadically increased resistance to trimethoprim-sulfamethoxazole, tetracycline, gentamicin, and moxifloxacin; and no increased resistance to vancomycin, daptomycin, linezolid, and rifampin.
Treatment of animal bites requires bacterial coverage that is particular to the offending animal. Human bites require coverage for Eikenella corrodens; penicillin and a first-generation cephalosporin are appropriate choices in these cases. Cat bites require coverage for Pasteurella multocida ; IV ampicillin-sulbactam or oral amoxicillin-clavulanate is an appropriate choice in these cases.
Usually, oral antibiotics are sufficient as initial treatment. Many medical professionals recommend an initial limited wound irrigation in the emergency department or in the outpatient clinic. IV antibiotics should be considered for patients whose cellulitis does not resolve with oral antibiotics. In all cases, the final antibiotic coverage should be guided by culture and sensitivity results. Patients with a history of immunocompromise (including those with diabetes) should initially be treated with IV antibiotics.
Fungal infections can occur in or under the skin. Cutaneous fungal infection, or tinea, is treated with topical agents such as miconazole or clotrimazole. The most common subcutaneous infection is sporotrichosis; this condition can appear with an ulcerative lesion, along with lymphadenopathy. Gardeners are most commonly infected. Oral itraconazole for 3-6 months is the current recommended course of treatment. Fungal abscesses or disseminated fungal infections can occur and are usually found in immunocompromised patients.
As a rule, all abscess cavities must be drained. Antibiotics alone are not effective in treating pus. If the patient does not improve with antibiotics, suspect undrained pus or a foreign body. Immunocompromised patients should always receive IV antibiotics.
Preparation for operation
Before surgery, obtain a thorough patient history, and perform a thorough physical examination. The operating surgeon must counsel each patient about the appropriate risks and benefits of each procedure. Furthermore, consent for sufficient latitude in performing the procedure (eg, possible amputation) is necessary. Patients should always be preoperatively informed that further operations may be necessary.
In the operating room, perform all explorations and debridements under tourniquet control. The extremity should be exsanguinated by gravity. Obtain wound cultures before the administration of antibiotics; then administer a dose of perioperative antibiotics because of the likelihood of a transient bacteremia after debridement.
Intraoperative cultures should include tests for aerobic, anaerobic, fungal, mycobacterial, and atypical mycobacterial organisms. Debride all devitalized tissue, and thoroughly irrigate all wounds. Treat larger wounds with pulse lavage and antibiotic irrigation. A repeat exploration and a second operative irrigation and debridement are necessary for certain wounds.
At the time of the operation, an incision is made in the distal area of the palm over the proximal end of the flexor sheath. The sheath is incised, and the presence of cloudy fluid or pus in the sheath is a clear indication of tenosynovitis. A second midaxial incision is made distally in the digit to provide access to the distal end of the tendon sheath. An irrigation catheter is placed through the sheath, and continuous irrigation of the sheath (usually with saline or antibiotic solution) is performed for 48 hours.
Be cognizant of the presence of digital swelling due to overly aggressive irrigation. It is possible to cause digital necrosis. If signs of infection have improved, the drainage system can be removed, and the patient should receive a course of antibiotics with elevation of the affected area.
Deep palm and web-space infections
The incision should be centered over the area of fluctuance. Incisions can be made along the palmar creases when possible. In the case of deep-space infections, wide exposure is important. The palmar fascia is incised, and the common digital nerves and vessels should be identified and protected when possible. A palmar and dorsal incision may be necessary, particularly in the case of collar button abscesses.
Arthrotomy is necessary to adequately treat septic arthritis. For the MCP joint, a dorsal incision can be used. The extensor mechanism is split in the midline, and the joint capsule is incised. In the case of proximal IP joint infections, a dorsal incision can be used, but when dividing the extensor tendon, one must be careful to preserve the central slip. Alternatively, a midaxial incision can be made. The joint is entered by incision of the accessory collateral ligament.
The joint space must be copiously irrigated, and the fibrinous and synovial debris is debrided. The wound can be packed to allow for continuous bedside irrigation, or if joint debridement has been adequate, the wound can be loosely closed.
In cases of chronic osteomyelitis, surgical debridement is required. The sequestrum or devitalized bone must be removed. Similarly, in cases of acute osteomyelitis, debridement of the denuded bone is important for obtaining microbiologic cultures and for treatment. Once acute and chronic infections have been resolved, bony reconstruction may be necessary.
Immobilization, with splinting of the hand in the position of safety (wrist extension of 15-30°, MCP flexion of 70-90°, and IP extension), is important in reducing joint contractures. Furthermore, elevation is a critical aspect of hand infection management. Often, adequate elevation and immobilization require the patient's hospitalization. Once the infection resolves, patients should begin early mobilization therapy. The patient should begin range-of-motion exercises and be seen by a hand therapist as soon as possible to minimize postinfection stiffness.
Most complications from hand infections result from inadequate treatment. Inadequacies in treatment can be life-threatening in patients who are immunocompromised. Joint contracture from prolonged immobilization can be functionally devastating.
Recurrent infections or polymicrobial infection of the hand frequently complicates the care of the immunocompromised patient.[2, 19, 26]
Patients require close follow-up for the first several weeks after the infection. The surgeon should remain vigilant for any recurrence of infection and for appropriate compliance with wound care and hand therapy.
Once the infection resolves, aggressive hand therapy regimens should be started. Swelling from the infection itself and prolonged immobilization lead to the significant formation of adhesions and joint stiffness. Encourage patients not to guard their hands but, rather, to use them as much as possible. This step is particularly crucial if the patient has undergone surgical debridement, including treatment for tenosynovitis.
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