Orthopedic Surgery for Hand Infections Workup

Updated: Oct 22, 2019
  • Author: Matthew B Klein, MD; Chief Editor: Harris Gellman, MD  more...
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Workup

Laboratory Studies

A complete blood count (CBC) should be obtained. An elevated white blood cell (WBC) count can indicate the presence of infection. In the case of particularly severe infections, the CBC may provide a measure of the patient's progress.

A prothrombin time (PT) and an activated partial thromboplastin time (aPTT) should be obtained before surgical treatment in patients who are receiving long-term anticoagulant therapy.

Glucose levels should be checked in all patients with a history of diabetes. In those patients with active infections, blood glucose levels are often elevated and difficult to control. Furthermore, blood glucose control is important for wound healing. It is also important to check the glucose levels of any patient who has a history of frequent or particularly severe infections to rule out occult diabetes.

In general, the chemistry panel should be checked in patients who have a history of dehydration (secondary to vomiting or sepsis). The chemistry panel of elderly patients should be checked before surgery.

The erythrocyte sedimentation rate (ESR) is elevated in cases of septic arthritis and osteomyelitis. However, patients with inflammatory arthritis may have elevated ESRs without infection.

If there is a clinical suspicion of septic arthritis, a joint aspirate should be sent for Gram staining, culturing, and sensitivity testing. In addition, cell count assessment, glucose and protein level determinations, and crystal analysis help in distinguishing between an infected joint and a joint with inflammatory arthritis or gout/pseudogout.

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Imaging Studies

Plain radiographs (with three views of the hand) are important to rule out the presence of foreign bodies, fractures, and subcutaneous air, which could indicate gas gangrene or acute or chronic osteomyelitis.

Magnetic resonance imaging (MRI) may be helpful for assessing soft-tissue abscess and osteomyelitis. In a study by Eshed et al, flexor tenosynovitis as identified on MRI of the hand and wrist was found to be a strong predictor of early rheumatoid arthritis, with a sensitivity of 60% and a specificity of 73%. When MRI was combined with a positive serum rheumatoid factor (RF), sensitivity was 83% and specificity 63%; and when MRI was combined with serum anti-cyclic citrullinated peptides (CCP), sensitivity was 79% and specificity 73%. [22]

Ultrasonography (US) may reveal one or more soft-tissue abscesses. [23]

Bone scanning, indium-111 (111In) radionuclide studies, or computed tomography (CT) may be useful for evaluating osteomyelitis. Multidetector CT (MDCT) appears promising for detecting acute infections of the hand and wrist. [24]

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