Hand Infections in Emergency Medicine Treatment & Management

  • Author: Rohini J Haar, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Jan 13, 2011
 

Emergency Department Care

Paronychia

In acute paronychia, if no frank abscess or fluctuance is noted along the lateral nail edge, frequent hot soaks and possibly a short course of antibiotics may result in resolution of the infection.

If pus is present, drainage of the area is required. Perform a digital nerve block using lidocaine without epinephrine. Using a No 11 scalpel blade held parallel to the nail, elevate the lateral nail fold at the site of the abscess to allow for drainage of pus. If a large amount of pus is expelled, a small wick is left in the incision to allow for continued drainage. If pus has tracked beneath the nail, the removal of an adjacent longitudinal section of the nail may be necessary to promote drainage. If a subungual abscess results in a floating nail, remove a portion of the nail or trephinate the nail to allow for complete drainage.

After drainage and wick placement, dress the finger appropriately.

Update tetanus booster status as needed.

In chronic paronychia, treatment consists of avoiding predisposing factors and initiating topical steroids and antifungal agents.[4] Surgical intervention is indicated only if medical treatment fails. See the image below.

Paronychia incision and drainage. Paronychia incision and drainage.

Felon

If frank abscess formation is present or the finger pad is tense, incision and drainage is indicated. This should not be undertaken lightly because improper placement of the incision can lead to scarring, sensory loss, unnecessary pain, instability of the finger pad, and spread of infection into the adjacent tendon sheath.

Elevation of the eponychial fold with a No 11 blade is quick, usually painless, and effective, and if there is pain it is extremely brief, less so than the pain of a digital block so local anesthesia is not typically needed. Discuss the procedure with the patient to alleviate their fears. Extensive incision or penetration of the finger with the blade is unnecessary, simple elevation of the fold will do; therefore, no nerve block is needed. If the patient requests it, a digital nerve block can be performed for comfort.

A longitudinal incision over the area of greatest fluctuance is the safest procedure when incision and drainage is required. Many other procedures, including hockey-stick or fish-mouth shaped incisions, are no longer recommended because of injury to neurovascular structure.

To avoid penetration of the tendon sheath, the incision should not extend to the distal interphalangeal crease. Using a hemostat, bluntly dissect the wound to promote drainage. Irrigate the cavity copiously and loosely pack with a gauze wick. After irrigation and loose packing of the wound, apply a dry gauze dressing and overlying splint. Update tetanus booster status as needed.

Herpetic whitlow

Apply a dry gauze dressing to the affected finger to prevent further spread of the lesion.

Infectious tenosynovitis and/or deep fascial space infections

ED care consists of making the correct diagnosis, providing pain relief, initiating antibiotic therapy, elevating and immobilizing the hand, and consulting an experienced hand surgeon promptly for definitive treatment. Experienced surgeons in the operating room should perform the incision and drainage.

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Consultations

Prompt consultation with an experienced hand surgeon is indicated for patients with evidence of infectious tenosynovitis, deep fascial space infections, or osteomyelitis.

Cases of chronic paronychia that do not respond to initial therapy should be referred to a dermatologist.

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

Gregory S Johnston, MD  Attending Physician, Beth Israel Medical Center

Gregory S Johnston, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Dan Danzl, MD  Chair, Department of Emergency Medicine, Professor, 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, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eric L Weiss, MD, DTM&H  Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine

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 Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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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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