5/12/2017 - PDF Document

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  1. 5/12/2017 EMERGENT HAND INFECTIONS Milan Patel, M.D. Resurgens Orthopaedics ACKNOWLEDGEMENTS  Steve K. Lee, MD Associate Professor, Orthopaedic Surgery Hospital for Special Surgery Weill Cornell Medical College New York, NY  Robert Kaufmann, MD Department of Orthopaedic Surgery Division of Hand and Upper Extremity Surgery University of Pittsburgh Medical Center INFECTIONS Considerable morbidity Expeditious treatment minimizes permanent dysfunction RK 1

  2. 5/12/2017 Necrotizing Fasciitis • Aggressive life- and limb-threatening infection with rapid soft-tissue necrosis • Bullae and subcutaneous fat liquefaction within days of onset: “dishwater pus” • Systemic findings present: hemodynamic instability, leukocytosis, fever, shock SKL Necrotizing Fasciitis • 50% of cases due to Group A Streptococcus • Other species: • α- and β-hemolytic Streptococcus • Staphylococcus sp. • Anaerobes (Clostridium sp.) • Vibrio vulnificus SKL Necrotizing Fasciitis • Prompt recognition is essential to spare life and limb • Aggressive debridement of skin and subcutaneous tissues • Antibiotics • Resuscitation • Muscle typically spared SKL 2

  3. 5/12/2017 PARONYCHIA Infection beneath the eponychial fold Disruption of seal between nail plate and nail fold Allows entry of bacteria into eponychial space. RK 3

  4. 5/12/2017 PANONYCHIA: TREATMENT Provide drainage Fold lifted to allow drainage Partial nail elevation and excision if subungal extension Gauze maintains drainage Appropriate Abx RK FELON Subcutaneous abscess of distal pulp Closed, poorly compliant compartment with multiple septae Preceded by penetrating injury Rapid pain and swelling Abscess breaks down septae Invades bone Skin necrosis RK FELON: TREATMENT Incisions controversial Avoid injury to digital vessels Avoid disabling scar Do not violate flexor tendon sheath Provide adequate drainage RK 4

  5. 5/12/2017 FLEXOR TENOSYNOVITIS Flexor sheath - closed space extending from A1 pulley to DIP Thumb sheath contiguous with radial bursa Small finger sheath contiguous w/ ulnar bursa 50-80% of people have communicating radial/ulnar bursa RK FLEXOR TENOSYNOVITIS Bacterial infection Penetrating trauma Hematogenous spread for gonococcus S aureus most common Rarely mycobacteria RK KANAVEL’S CARDINAL SIGNS Flexed resting position Tenderness over flexor sheath Severe pain on passive extension Fusiform swelling (“sausage digit”) RK 5

  6. 5/12/2017 FLEXOR TENOSYNOVITIS TREATMENT Emergent treatment Delay leads to vascular compromise of tendon, necrosis, adhesions, and poor gliding -- Stiffness Early infections (first 24-48 hrs) may be treated with IV abx, elevation, splinting If no improvement noted in 24 hrs, surgical treatment is necessary SKL PYOGENIC FLEXOR TENOSYNOVITIS • No need for post op irrigation – results same whether you do or not Lille et al J Hand Surg B 2000 SKL 6

  7. 5/12/2017 RADIAL AND ULNAR BURSAL INFECTIONS • If they connect (in Parona’s space), then “horseshoe abscess” SKL DEEP SPACE INFECTIONS IN THE HAND • Web space • Midpalmar space • Thenar space • Hypothenar space SKL 7

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  10. 5/12/2017 MIDPALMAR SPACE INFECTIONS • Can result from penetrating wound, rupture of septic tenosynovitis, or distal palmar abscess ANATOMY: MIDPALMAR SPACE 10

  11. 5/12/2017 TECHNIQUE: I & D OF MIDPALMAR SPACE INFECTIONS 11

  12. 5/12/2017 THENAR SPACE INFECTIONS 12

  13. 5/12/2017 ANATOMY: THENAR SPACE TECHNIQUE: I & D OF THENAR SPACE INFECTIONS 13

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  15. 5/12/2017 SKL SKL 15

  16. 5/12/2017 SKL SKL SKL 16

  17. 5/12/2017 SKL HYPOTHENAR SPACE INFECTIONS • HYPOTHENAR SPACE: hypothenar muscles • Extremely rare infection • RX: palmar longitudinal incision, from wrist crease distally 3 cm in line with ulnar border of 4th ray. Spread through hypothenar fascia HUMAN BITES Clenched fist injuries with wound over MC head  Involve MCP joint  May appear innocuous if examined with MCP extended  Retraction of laceration in extensor mechanism RK 17

  18. 5/12/2017 HUMAN BITES Surgical I&D IV Abx Ampicillin/sulbactam PCN allergy: Clindamycin and quinolone repeat I&D at 48 hrs if necessary wound left open to heal Tendon repairs done in delayed fashion •Must cover for Eikanella corrodens (7% - 29%) •Bacteroides - most common anaerobes 18