Hand Infections in Emergency Medicine Follow-up

Patients with evidence of infectious tenosynovitis or deep fascial space infections require inpatient treatment consisting of parenteral antibiotics and definitive incision and drainage by an experienced hand surgeon.

Inpatient splinting and occupational therapy for range of motion is essential to preserve function.

Paronychia

Instruct the patient with acute paronychia to soak the affected finger 3-5 times per day in warm water.

If a wick was placed, the patient usually can remove it easily after 24 hours if it has not fallen out already.

Schedule follow-up care with the primary care doctor or at the ED for 48 hours after initial incision.

Antibiotics, if prescribed, should be continued for 3-5 days.

In cases of chronic paronychia, topical steroids and antifungal agents should be initiated.

Pain medication may be prescribed as indicated.

Felon

Reevaluate the wound 48 hours after initial incision.

At this time, remove the packing and irrigate the wound.

If continued drainage is present, loosely repack the wound and schedule another follow-up appointment in 24 hours.

If no further drainage is present, repacking is unnecessary.

Instruct the patient to keep the wound clean by washing it twice daily with warm, soapy water followed by a clean gauze dressing.

The patient should continue antibiotics for 5-7 days.

Pain medication may be prescribed as indicated.

Herpetic whitlow

Instruct the patient to keep the affected area clean and covered with a dry dressing to prevent further transmission of the virus.

Oral acyclovir may be involved in preventing recurrence or in immunocompromised patients.

Pain medication may be prescribed as indicated.

Emergency medicine physicians should feel competent and comfortable with the treatment of paronychia, felons, and herpetic whitlow.

Because of the specialized care required for infectious tenosynovitis and deep fascial space infections, transfer of patients with such infections may be necessary if those services are not available at the presenting hospital.

Prior to transfer, splint the affected area, update tetanus booster as needed, and initiate antibiotic therapy.

All care should be taken to avoid manicures or other salon procedures with unclean implements. Proper hand hygiene should be observed.^[7]

All wounds and abrasions to the hand should be taken seriously and thoroughly cleaned and dressed until healed. Careful observation and prompt medical evaluation prevents complications.

Paronychia

• Subungual abscess
• Osteomyelitis of the distal phalanx
• Development of a felon
• Chronic infection

Felon

• Osteomyelitis of the distal phalanx
• Skin pulp necrosis
• Sinus tract formation
• Septic joint
• Tenosynovitis
• Inappropriate incision and drainage technique, resulting in sensory loss, tendon injury, spread of infection, or instability of the finger pad

Herpetic whitlow

• Oral inoculation or transmission of virus
• Inappropriate treatment (eg, misdiagnosed as a felon) with incision and drainage, allowing viral spread into healthy tissue
• Viremia occurrence possible

Infectious tenosynovitis

• Tendon destruction
• Functional disability
• Extension of infection to deep fascial space

Deep fascial space infection

• Functional disability
• Tendon destruction
• Sepsis
• Hand loss

Paronychia

Most resolve in 2-4 days.

Chronic infections are likely fungal infections and are typically more difficult to treat.

Felon

The prognosis is good, with healing in 1-2 weeks.

Herpetic whitlow

Infection usually resolves in 2-4 weeks.

Recurrence is not uncommon because virus may lay dormant in neural ganglia.

Infectious tenosynovitis and/or deep fascial space infection

These have a fair prognosis, depending on the extent of tissue destruction, bony involvement, preexisting vascular insufficiency, and systemic complications (eg, bacteremia, sepsis).

• Instruct patients on proper wound care including warm soaks, if indicated, and dressing changes.
• Inform patients of the signs and/or symptoms of worsening infection, including increased pain, edema, redness, warmth, or fever.
• Emphasize the importance of follow-up care and wound reevaluation with the primary medical doctor or the ED physician.
• Instruct patients to avoid predisposing factors, such as nail biting, manicuring, and repeated exposure to water and/or irritants.
• For excellent patient education resources, visit eMedicine's Infections Center and Hand, Wrist, Elbow, and Shoulder Center. Also, see eMedicine's patient education articles Paronychia (Nail Infection), Finger Infection, Hand Injuries, and Finger Injuries.