Hand Infections in Emergency Medicine Clinical Presentation

Paronychia

• 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 that 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].)^[3]

Felon

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

Herpetic whitlow

• 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

• 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

• 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

Paronychia

• 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

• 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

• 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 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

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.