Rosen & Barkin's 5-Minute Emergency Medicine Consult (312 page)

• Hand infections are commonly seen in the ED.
  
• The range of pathology is broad and may include acute
  and
  chronic conditions.
  

• Bacterial infection of the hand is associated with skin pathogens:
  
  • Staphylococcus or Streptococcus spp
    
  • History of a puncture wound
    
• Anaerobes are identified in 75% of paronychia in children owing to thumb sucking and nail biting.
  
• Chronic paronychia may be caused by
  Candida albicans
  .
  
• Herpetic whitlow is caused by type 1–2 herpes simplex virus.
  
• Clenched fist injuries involve a variety of pathogens, including anaerobic Streptococcus and Eikenella spp.
  

DIAGNOSIS

• Paronychia:
  
  • Localized edema, erythema, and pain in proximal portion of lateral nail fold
    
  • Fluctuance may be present and may extend beneath the nail margin.
    
  • Systemic signs and symptoms are usually not present.
    
• Felon:
  
  • Erythema and tense swelling of the distal pulp space that does
    not
    extend proximal to the proximal interphalangeal (PIP) joint
    
  • Aching pain early, severe throbbing pain late
    
  • Systemic signs are usually not present.
    
• Herpetic whitlow:
  
  • Distal pulp space is swollen, but remains soft.
    
  • Lateral nail folds may be affected.
    
  • Throbbing pain of the distal pulp space
    
  • Vesicles containing nonpurulent fluid are present and may form bullae.
    
  • Systemic symptoms may be present:
    
    • Fever
      
    • Lymphadenopathy
      
    • Constitutional symptoms
      
• Flexor tenosynovitis:
  
  • Kanavel signs:
    
    • Severe pain and symmetric edema of the digit
      
    • Tenderness over the course of tendon sheath
      
    • Flexed position of the finger at rest
      
    • Pain on passive extension of the finger—may be the only finding in early infection
      
• Clenched fist injury:
  
  • Laceration over the metacarpophalangeal (MCP) joint from striking an object with a clenched fist
    
  • Any laceration over the MCP must be assumed to be a
    human bite wound
    until proven otherwise.
    
• Web space abscess:
  
  • Pain and edema of the affected web space and adjacent palm
    
  • Fingers are held abducted.
    
• Palmar space infections:
  
  • Thenar space infection:
    
    • Pain, tenderness, tense edema of thenar eminence
      
    • Dorsal edema without tenderness
      
    • Thumb is held abducted and flexed, and passive adduction is painful.
      
  • Midpalmar space infection:
    
    • Pain, edema, and tenderness of the midpalmar space
      
    • Dorsal edema without tenderness
      
    • Motion of middle and ring fingers is painful
      
  • Hypothenar space infection:
    
    • Pain and fullness over hypothenar eminence
      
    • No limitation of finger movement
      

See Signs and Symptoms.

See Signs and Symptoms.

Most hand infections are diagnosed by history and physical exam with special attention to neurovascular status.

• Although usually not necessary, herpetic whitlow may be confirmed by Tzanck test.
  
• Gram stain and culture may guide antibiotic choice in felons.
  
• Blood cultures, CBC are not routinely indicated.
  

• Radiographs are usually not helpful unless there has been trauma or a suspected foreign body.
  
• With felon, flexor tenosynovitis, and palmar space infection, radiograph may identify osteomyelitis or foreign body.
  
• Radiographs in clenched fist injury may reveal a fracture.
  

• Paronychia should be differentiated from herpetic whitlow and felon.
  
• The differential for palmar space infection includes flexor tenosynovitis, cellulitis, and web space infection.
  

TREATMENT

Hand immobilization as appropriate

• Paronychia:
  
  • Early paronychia/simple cellulitis without purulence present may be managed with oral antibiotics and rest:
    
    • Cephalexin, dicloxacillin
      
    • Clindamycin or erythromycin, if associated with nail biting or oral contact
      
  • Superficial infections are drained by inserting a No. 11 blade between nail and eponychium, and lifting the eponychium from the nail.
    
  • If necessary, the lateral nail fold may be incised tangential to the curvature of the nail.
    
  • When pus is present under the adjacent nail, 1/4 of the nail should be removed.
    
  • When pus is present under the dorsal roof of the proximal nail, remove 1/3 of the proximal nail.
    
• Felon:
  
  • A lateral incision avoiding the neurovascular bundle is preferred.
    
  • More extensive felons are drained through a unilateral longitudinal incision that does not cross the distal interphalangeal (DIP) flexor crease.
    
  • Disruption of fibrous septa is no longer recommended:
    
    • Results in an unstable fingertip
      
    • Loculations may need to be broken up.
      
  • Give oral antibiotics to cover skin pathogens, place a drain, and recheck in 48 hr:
    
    • Cephalexin, dicloxacillin
      
• Herpetic whitlow:
  
  • Usually self-limited; do not incise and drain.
    
  • Oral acyclovir may be given to patients with systemic involvement.
    
• Flexor tenosynovitis, web space abscess, palmar space infection:
  
  • Elevation, IV antibiotics, and pain control:
    
    • Ampicillin/sulbactam, cefoxitin, ticarcillin/clavulanate
      
  • All of these infections require immediate consultation with a hand surgeon.
    
• Clenched fist injury:
  
  • Elevation, IV antibiotics, tetanus prophylaxis, and pain control in the ED:
    
    • Ampicillin/sulbactam, cefoxitin, ticarcillin/clavulanate
      
  • All bite wounds with evidence of infection or joint involvement require emergent consultation with a hand surgeon.
    
  • If there are no signs of infection and no joint penetration, patients may be considered for outpatient treatment with oral antibiotics after appropriate irrigation and wound care:
    
    • Ampicillin/clavulanate or penicillin V + cephalexin or dicloxacillin
      
    • Do
      not
      primarily close lacerations associated with a human bite; delayed primary closure or healing by secondary intention is appropriate.
      

• Acyclovir: 400 mg PO TID for 10 days (peds: Not recommended for herpetic whitlow)
  
• Amoxicillin/clavulanate: 875/125 mg PO BID (peds: 40 mg/kg/d PO div. q6h)
  
• Ampicillin/sulbactam: 1.5–3 g IV q6h (peds: Safety not established)
  
• Cefoxitin: 2 g IV q8h (peds: 80–160 mg/kg/d IV or IM div. q6h)
  
• Cephalexin: 500 g PO QID for 7 days (peds: 40 mg/kg/d PO div. q6h)
  
• Clindamycin: 300–450 mg PO QID for 7 days. Can use IV in severe cases: 600–900 mg IV q8h (peds: 20–40 mg/kg/d div. q8h PO IV or IM)
  
• Dicloxacillin: 500 mg PO QID for 7 days (peds: 12.5–50 mg/kg/d PO div. q6h)
  
• Erythromycin: 500 mg PO QID for 7 days (peds: 40 mg/kg/d div. q6h PO)
  
• Penicillin V: 250 mg PO QID (peds: 40 mg/kg/d PO div. q6h)
  
• Ticarcillin/clavulanate: 3.1 g IV q4–q6h (peds: 150–300 mg/kg/d IV div. q6–8h)
  

Tailor to etiology

Tailor to etiology

FOLLOW-UP

• Flexor tenosynovitis, web space abscess, palmar space infections:
  
  • All these infections require admission for IV antibiotics and drainage.
    
• Clenched fist injury with signs of infection:
  
  • Requires admission for surgical débridement and IV antimicrobials
    

• Paronychia and felons:
  
  • Patients with uncomplicated paronychia or felon may be discharged from the ED with a recheck and drain removal in 48 hr.
    
• Herpetic whitlow:
  
  • Patients with herpetic whitlow may be discharged from the ED with appropriate follow-up.
    
• Clenched fist injury without infection:
  
  • May be discharged on oral antibiotics with follow-up in 24 hr
    

Immediate consultation in emergency department is indicated

Usually arranged by admitting physician after operative therapy

• Missed or delay in diagnosis
  
• Failure to obtain history of clenched fist injury
  
• Failure to consult surgeon promptly
  

• Antosia RE, Lyn E. The hand. In: Rosen P, et al., eds.
  Emergency Medicine: Concepts and Clinical Practice
  . 4th ed. St. Louis, MO: Mosby, 1997;1998:625–668.
  
• Bach HG, Steffin B, Chhadia AM, et al. Community-associated methicillin-resistant Staphylococcus aureus hand infections in an urban setting.
  J Hand Surg Am
  . 2007;32(3):380–383.
  
• Ong YS, Levin LS. Hand infections.
  Plast Reconstr Surg
  . 2009;124(4):225e–233e.
  

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