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Hand Infections Clinical Presentation

  • Author: Jordan Scaff, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Jan 11, 2016
 

History

Paronychia

See the list below:

  • Recent trauma to the lateral nail fold
  • In acute paronychia, history of nail biting or manicuring
  • In chronic paronychia, history of repeated exposure to water and/or irritants (Those at risk may include people who frequently wash dishes or perform housekeeping duties.)
  • In children, history of finger sucking
  • Erythema and pain in early stages, followed by frank abscess formation with increased pain
  • History of diabetes (One study found that pediatric and adolescent patients with type 1 diabetes mellitus had an increased frequency of paronychia over the control group [34.4% vs 23%, respectively].)[4]

Felon

See the list below:

  • Recent trauma to finger pad
  • Pain, typically throbbing in nature
  • Swelling, pressure, and erythema
  • Presence and/or progression from paronychia

Herpetic whitlow

See the list below:

  • Genital herpes in self or partner
  • Health care worker (not as common as once believed, likely secondary to increased protection with standard body-substance precautions)
  • Children with gingivostomatitis
  • Most commonly on tip of finger rather than on shaft
  • Localized pain, pruritus, and swelling followed by the appearance of clear vesicles
  • Typically localized to 1 finger only (symptoms involving more than 1 finger are more typical of coxsackievirus infection)

Infectious tenosynovitis

See the list below:

  • Recent penetrating trauma to the hand
  • Gonococcal infection, particularly disseminated infection
  • Pain, especially with passive extension of the finger
  • Edema of the entire finger
  • Variable history of fever

Deep fascial space infection

See the list below:

  • Recent penetrating trauma to the hand
  • Recent or untreated tenosynovitis
  • Palmar blister (may result in subfascial web space abscess)
  • Pain and edema of the hand
  • Pain with movement of the fingers
  • Variable history of fever
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Physical

Paronychia

See the list below:

  • Edema, erythema, and pain along lateral edge of the nail fold
  • May have extension to the proximal nail edge (eponychium)
  • Presence of frank abscess formation and fluctuance, although less common in chronic cases
  • Subungual abscess (floating nail) if pus has extended under the nail plate

Felon

See the list below:

  • Painful, tense, and erythematous finger pad
  • Pointing of abscess possibly present
  • Signs typically limited to area distal to the distal interphalangeal joint because of anatomic constraints
  • Evidence of penetrating trauma

Herpetic whitlow

See the list below:

  • Clear vesicles on an erythematous border localized to one finger
  • Pain, typically out of proportion to findings
  • Edema
  • Turbid or cloudy fluid in vesicles, possibly suggesting a superimposed pyogenic infection
  • In later stages, coalescence of vesicles to form an ulcer
  • Distal finger pulp that remains soft, which may help distinguish herpes simplex virus (HSV) infections from bacterial felons

Infectious tenosynovitis

The 4 cardinal signs, first described by Kanavel, include the following:

  • Tenderness along the course of the flexor tendon
  • Symmetric edema of the involved finger
  • Pain on passive extension (believed by some authors to be the most important sign)
  • Flexed resting posture of finger

All 4 signs are possibly not present early in the course of infection. Patients may have associated lymphangitis, lymphadenopathy, and fever.

Deep fascial space infections

Deep fascial space infections all possibly present with lymphangitis (identified dorsally), lymphadenopathy, and fever.

  • Dorsal subaponeurotic abscesses - Result in swelling and pain on the dorsum of the hand and pain with passive movement of the extensor tendons (difficult to distinguish from dorsal subcutaneous infection)
  • Subfascial web space infections - Present with pain and swelling on the dorsum and palmar surfaces of the hand (Because the subfascial space is contiguous with the dorsal subcutaneous space, tracking of infection from the former to the latter results in a collar button abscess named for its hourglass shape.)
  • Midpalmar space infections - Present with pain, swelling, loss of palmar concavity, pain with movement of the third and fourth digits, and dorsal swelling secondary to the tracking of infection dorsally along the lymphatics
  • Thenar space infections - Result in marked swelling of the thumb-index web space, flexed and abducted resting posture of the thumb, and pain with passive adduction
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Causes

Paronychia

Staphylococcus aureus and Streptococcus species are most common in acute cases.

Candida albicans (95%) and atypical mycobacteria are causes in chronic cases and in patients who are immunocompromised.

Anaerobes may be involved in the pediatric population secondary to finger sucking and children's playing in unhygienic spaces.

Felon

S aureus is the most common causative organism, but gram-negative organisms have been identified.

Herpetic whitlow

HSV-1 or HSV-2 is responsible.

Infectious tenosynovitis

S aureus and Streptococcus species are commonly isolated; however, some authors believe that N gonorrhoeae should be considered a possible pathogen until excluded by culture data.

Eikenella corrodens is observed in infections caused by human bites.

Pasteurella multocida and Capnocytophaga infections caused by cat and dog bites can progress rapidly to septic shock and death.

Deep fascial space infections

S aureus and Streptococcus species are most commonly isolated.

Organisms mentioned for infectious tenosynovitis also apply to deep space infections. This may be the result of local spread from infected neighboring tendon sheaths.

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Contributor Information and Disclosures
Author

Jordan Scaff, MD Resident Physician, Department of Emergency Medicine, Mount Sinai Beth Israel

Jordan Scaff, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Gregory S Johnston, MD Assistant Professor of Emergency Medicine, Mount Sinai Beth Israel

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Dan Danzl, MD Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Rohini J Haar, MD Staff Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center

Rohini J Haar, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Amy K Rontal, MD, and Heatherlee Bailey, MD, to the development and writing of this article.

References
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  2. Ong YS, Levin LS. Hand infections. Plast Reconstr Surg. 2009 Oct. 124(4):225e-233e. [Medline].

  3. Pintor E, Montilla P, Catalán P, Burillo A, Gargantilla P, Herreros B. Recurrent infection in the left thumb. Infection. 2013 May 7. [Medline].

  4. Kapellen TM, Galler A, Kiess W. Higher frequency of paronychia (nail bed infections) in pediatric and adolescent patients with type 1 diabetes mellitus than in non-diabetic peers. J Pediatr Endocrinol Metab. 2003 Jun. 16(5):751-8. [Medline].

  5. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. 2001 Mar 15. 63(6):1113-6. [Medline].

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  9. Ergun A, Toprak R, Sisman FN. Impact of a Healthy Nails Program on Nail-Biting in Turkish Schoolchildren: A Controlled Pretest-Posttest Study. J Sch Nurs. 2013 Mar 14. [Medline].

  10. Antosia RE, Lyn E. Hand. Rosen, ed. Emergency Medicine Concepts and Clinical Practice. 5th ed. 2002. 493-535.

  11. Butler, KH. Incision and drainage. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. 2004. 739-744.

  12. Daniel CR 3rd, Daniel MP, Daniel J, Sullivan S, Bell FE. Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen. Cutis. 2004 Jan. 73(1):81-5. [Medline].

  13. Gill MJ, Arlette J, Buchan K. Herpes simplex virus infection of the hand. A profile of 79 cases. Am J Med. 1988 Jan. 84(1):89-93. [Medline].

  14. Goldstein EJ, Barones MF, Miller TA. Eikenella corrodens in hand infections. J Hand Surg [Am]. 1983 Sep. 8(5 Pt 1):563-7. [Medline].

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  17. Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999 Jan 14. 340(2):85-92. [Medline].

  18. Wolanyk DE. 17. Infections. Hart RG, Uehara DT, Wagner MJ, eds. Emergency and Primary Care of the Hand. Irving,Tx: The American College of Emergency Physicians; 2001. 219-246.

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A paronychia can progress to a felon if left untreated.
A herpetic whitlow. Image courtesy of Glen Vaughn, MD.
Paronychia incision and drainage.
 
 
 
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