1. Dr. Tauseef ul Hassan

2. approx 35% of patients admitted to hand surgeryservices. Majority are result of minor trauma for whichtreatment is delayed or neglected. Occasionally these are results of drainage efforts bypatients themselves under aseptic conditions. 3. Uncomplicated Infections: Antiobitics alone will suffice. Evolved infections with localized collections: Antiboitics Drainage. 4. Any surgeon who accepts the responsibility fordrainage of a hand infection must undertakecomprehensive management responsibilities including: Preoperative Planning Surgical Approach Postoperative Care Rehabilitation. 5. A. EvaulationB.Operative PrinciplesC. Rest/Heat/ElevationD. Inpatient Care 6. A: EVALUATION HISTORY:o Reveals the source of infection or predisposing factors.o Previous injury to the siteo Bites --- Splinter --- Needle sticks --- surgical procedureo Hand Dominance & Occupationo exposure to certain pathogens.o History of Systemic diseases like DM,immunocompromised states. 7. SYMPTOMS:o Timing of eventso Paino Loss of functiono Drainageo Fevero Chills. 8. Physical Examination:o Exposure of whole extremityo Signs of lymphangitis and lymphadenopathyo A systemic approach to avoid missing criticalinformation. 9. RADIOGRAPHS:o Retained foreign bodieso Rule out osteomyelitiso Gas gangreneo Serve as baseline for future comparison. 10. A. EvaulationB.OPERATIVE PRINCIPLESC. Rest/Heat/ElevationD. Inpatient Care 11. B: OPERATIVEPRINCIPLES1.Incisions should never cross a flexion crease at a right angle2. Avoid iatrogenic injury to critical structures 1. Tendons 2. Neurovascular bundles3. Incision lengthening is usually needed and should be planned by making potential extensions with a pen. 12. 4. Torniquet Control is helpful as infectiveprocesscan lead to profuse bleeding. o Finger Torniquet o Penrose drain o Glove technique o Standard Pnematic Torniquet with exanguination o Esmarch bandage o Elevation of limb with digital pressure on brachial artery. 13. A. EvaulationB.Operative PrinciplesC. REST/HEAT/ELEVATIOND. Inpatient Care 14. C: REST HEAT -ELEVATIONa. REST (IMMOBILIZATION) oLimits opening of tissue plans restricting the spreadof infection. oShould be done in a functional position. 15. b. HEAT (WARM MOIST SOAKS):o Maximum vasodilatory effect reached in 10 min.o Frequent soaks preffered over continous soaks.o Severe Infections:o Moist hot towels with plastic barrier and a dry towel asinsulator. 16. c. ELEVATION:o Reduces edema by improving venous/lymphaticdrainage.o Limb should be above level of heart for dependantdrainage.o Limb placed over chest or on a pillow while sitting. 17. A. EvaulationB.Operative PrinciplesC. Rest/Heat/ElevationD. INPATIENT CARE 18. D: INPATIENT CARE IV antiboitcs is the most common justification forhospitalization. Continuous or intermittent wound irrigation. Frequent dressing changes. Three phases of treatment in cases of severeinfections where extensive debridement andcomplex reconstructions are needed. 19. Phase 1> Rapid infection contrtol and stageddebridement. A second look surgery done in 24-48 hours. Phase 2> Salvage of vital structures and soft tissue coverage. With identification of structures that will later require reconstruction. Phase 3 > Reconstructive Surgery. Once stable soft tissue coverage is achieved. 20. ANTIMICROBIALTHERAPY Antiboitcs are indespensible adjuncts. Cultures should be obtained prior to antiboitics use. Most common pathogens involved are Staph auresand Streptococcus sp. Usually gram +ve coverage is first choice. Consider MRSA while treating infections dependingupon patterns of resistance in a particular area. 21. ACUTE PROCESSES:A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. Septic arthritisI. Necrotizing Fascitits. 22. A. CELLULITIS Virtually all hand infections begin as cellutitis. Symptoms: Pain Swelling Erythema Lymphadenopathy Lymphangitis. 23. Treatment: Oral antiboitics (usually gram +ve coverage) Rest Warm soaks Elevation. LYMPHANGITIS > Cellulitis accompained byerythematous streaks up the arm. 24. ACUTE PROCESSES:A. CellulitisB. PARONYCHIAC. FelonD. Palmer space infectionsE. Pyogenci (Supparative) Flexor TenosynovitisF. Bite woundsG. Septic arthritisH. Necrotizing Fascitits. 25. B: PARONYCHIA Infection of the soft tissues surrounding thefingernail and is the most common infection ofhand. 26. 27. 28. Cause: Inocculation of bacteria as a consequence of minortrauma such as Nail bitiing Poor manicuring Small puncutre wounds. Staph aureus is most common pathogen butanaerobes may also be involved. 29. UNCOMPLICATED INFECTION: Oral antiboitics / Rest / Heat / Elevation INFECTION WITH ABCESS: Localized to one nail fold; Elevation of fold bluntly with a haemostat Using no 11 blade directing away from nail bed throughthe insensate epithelium where abcess is pointing. 30. Eponychia (involving proximal nail & one lateral fold; Elevating the eponychial fold and removal of looseportion of nail plate to drain abscess and allow forsecondary healing. 31. ACUTE PROCESSES:A. CellulitisB. ParonychiaC. FELOND. Palmer space infectionsE. Pyogenci (Supparative) Flexor TenosynovitisF. Bite woundsG. Septic arthritisH. Necrotizing Fascitits. 32. C: FELONA felon is an abscess of the distal pulp of the thumb or finger. 33. 34. Pulp Anatomy: 15-20 longitudonal septa anchoring skin to distalphalanx dividing the pulp into multiple closedcompartments. 35. Pathophysiology: Abscess formation within these small compartmentsresults in rapid development of swelling andthrobbing pain, worsened by dependency. Complications: Necrosis of entire pulp Extension of infection into; Flexor tendon sheath Distal IP joint Distal phalanx. 36. Causes: Mostly Puncture wound with foreign body, so radiographsare mandatory. Pathogen: Staph aureus but gram ve infection can also occur esp inimmunocompromised patients. Conservative Management: For early Felons Oral antiboitics Rest Warm Soaks Elevation. 37. Basic principles of Incision drainage; Avoid iatrogenci injury to neurovascualar structure Leave an acceptable scar Avoid flexor tendon sheath Drain all fluid collections adequately. Two types of INCSIONS: Volar Longitudonal incision Hockey stick or J- inscion 38. 39. ACUTE PROCESSES:A. CellulitisB. ParonychiaC. FelonD. Herpetic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. Septic arthritisI. Necrotizing Fascitits. 40. D: HERPETIC WHITLOW Herpex simplex virus infection can be: Primary Recurrent Population at risk: Children, adolesents with genital herpes infection Health care workers with frequent exposure to oral secretions. Must be distinguished from Paronychia and Felonbecause incision and drainage is generallycontraindiacted. 41. 42. Pathophysiology: A prodromal phase of 24-72 hours of burning painprior to the development of skin changes. Erythema and swelling Formation of clear vesicles which sometimes coalseasearound nail fold. Fluid may become turbid but not frankly purulentunless bacterial superinfection occurs. Pulp of affected digit is not tense as in felon. 43. 44. Disease Course: The process occurs over approx 2 weeks and resolves over next 7-10 days. Diagnosis: Viral culture Tzanck smear Treatment: Generally conservative Rest & Elevation Anti inflammatory agents Acyclovir in immunocompromised states. Reccurence rates are around 20%. 45. ACUTE PROCESSES:A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. PALMER SPACE INFECTIONSF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. Septic arthritisI. Necrotizing Fascitits. 46. E: PALMER SPACE INFECTIONS Thenar space Midpalmer space (subtendinous space) Hypothenar space Dorsal subapeneurotic space Web spaces. Thenar and midpalmer spaces are clinically moreimportant. 47. THENAR SPACEINFECTIONMIDPALMER SPACEINFECTION 48. A penetrating injury usually a splinter is the mostcommon cause. Staph aureus is the usual pathogen. Antiboitics / Rest / Heat / Elevation for earlyinfections but most cases need Surgical Drainage. Key to success is adequate drainage while avoidingiatrogenic injury and subsequent scar contracutres. 49. Midpalmer space infectionincisions and proceedures: Curved longitudonal incision in the palm. Take care to avoid injury to superficial palmer archand digital vessels. Wound packed open with daily dressing changes.OR Irrigation catheter in proximal wound and a penrosedrain in distal wound for continous or intermittentirrigation. 50. Thenar space infection incision and procedure: Combined dorsal and volar incisions. Take care to avoid injury to palmer cutaneousbranch of median nerve in proximal end of incision And avoiding injury to motor branch of mediannerve. Post op care include Splinting Dressing changes Catheter irrigation. 51. 52. ACUTE PROCESSES:A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. PYOGENCI (SUPPARATIVE) FLEXOR TENOSYNOVITISG. Bite woundsH. Septic arthritisI. Necrotizing Fascitits. 53. F: PYOGENIC (SUPPARATIVE) FLEXOR TENOSYNOVITIS: Most serious hand infection. If left untreated; Destruction of glidingsurfaces in sheath Necrosis of tendons Osteomyelitis Amputation. Ring, middle and index fingers mostly involved Staph aureus usual pathogen with few cases due tohaematogeneous spread of gonococcal infection. 54. 55. KANAVEL cardinal sign of flexortenosynovitis:1. Fusiform swelling of finger2. Paritally flexed posture of digit3. Tenderness over entire flexor sheath4. Dipropotionate pain on passive extension. 56. < 48 hours of onset of infection: IV antiboitics Rest / Heat / Elevation > 48 hours of onset of infection: Surgical drainage with zig zag brunner incisions Wound is packed open and loosely approximated Early and aggressive hand therapy initiated. Less severe cases: Catheter irrigation with limited incision . 57. ACUTE PROCESSES:A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. BITE WOUNDSH. Septic arthritisI. Necrotizing Fascitits. 58. G: BITE WOUNDSa) HUMAN BITESb) ANIMAL BITES 59. a. Human bites: Potenitally serious due to high virulence of pathogensinvovlved. Common mechanism is clenched fist striking atooth, FIGHT BITE. Usually delayed presentation. Most commonly over the MCP joint, putting the extensormechanism and joint surface at risk. Radiographs are mandatory and may reveal; Tooth fragment Fracture of Metacarpel head Air in joint. 60. All human bites in MCP joint region should beexplored; Joint space irrigated Edges debrided Primary wound closure never done. Closed after a week or 10 days in severe cases Antiboitics / Rest / Heat / Elevation Usually covering gram +ve and anaerobes. 61. b. Animal bites:Domestic Dogs and CatsTetnus status should be ensured.Rabies prophylaxisThorough irrigation and exploaration of joints when potentially voilated. 62. Acute DOG bites; Sharpely debrided Loosely approximated Antiboitics / Rest / Heat / Elevation. Gram +ve and anaerobe coverage 63. CAT bites can present late with closed spaceabscesses due to trapping of bacteria inside wounds 64. CAT scratch FEVER; Small pustule with surrounding edema at site of catbite Painful lymphadenopathy Symptomatic treatment Anti inflammatory Antiboitics Pain resovlves in 2 weeks but lymphadenopathy canpersist for months or years. 65. ACUTE PROCESSES:A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. SEPTIC ARTHRITISI. Necrotizing Fascitits. 66. H: SEPTIC ARTHRITIS Destruction of articular surfaces. Mode of infection: Penetrating injury Local extension of adjacent infection Haematogenous spread (Gonococcal infection) Children; Streptococcus sp Staph aureus H. Infulenza Adults; with no history of trauma Suspect Gonococcus. 67. Presentation; Septic joint will be Swollen Tender warm Marked pain on passive motion. Patient position of hand is to allow maximum jointspace; IP joints in 30 degree flexion MCP full extension 68. Exploration is mandatory and joints are copiouslyirragated and debrided. Joint packed open and dressing changes performed. Wound left to close by secondary intention. Antiboitics Rest / Heat / Elevation. 69. ACUTE PROCESSES:A. CellulitisB. ParonychiaC. FelonD. Herptic WhitlowE. Palmer space infectionsF. Pyogenci (Supparative) Flexor TenosynovitisG. Bite woundsH. Septic arthritisI. NECROTIZING FASCITITS. 70. I: NECTROTIZING FASCITIS A life threatening, rapidly progressing infection ofthe subcutaneous tissue and fascia. Diabetics and immunocompromised patients are atgreater risk. 71. Pathogenesis; Low grade cellulitis bullous changes in skin cutaneous anesthesia with spread into underlying subcutaneous tissuefat necrosisvascular thrombosiMyonecrosiscutaneous vessel thrombosis. 72. Mixed infection; Aerobes Anaerobes Clostridium sp result in gas formation in tissues withcrepitus on physical exam and air in tissues onradiographs. Treatment: Repeated aggressive radical debridements Amputations above area of involvement Silvadene cream IV High dose antiboitics and tissue culture Hyperbaric O2. 73. CHRONICINFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS 74. A: CHORNICPARONYCHIA Presentation: Eponychium is; Indurated Erythamatous Occasional drainage from nail fold. Population at risk; Diabetics Frequent occupational exposure to moist conditions CANDIDA ALBICANS is the most commonpathogen. 75. Medical Management: Topical antifungal Topical steroids Removal of thickened, deformed nail plate. Surgical Management: Eponychial Marsupalization. 76. CHRONICINFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS 77. B: OSTEOMYELITIS Mode of infection: Direct extension from an adjacent infection Septic arthritis Flexor tenosynovitis After open fracture Haematogenous seeding. Causative Bacteria: Staph aureus Hemophilus sp in young children. 78. Presentation: Chronically draining wound Erythema Pain Swelling along the course of bone. Diagnosis: Radiographs Bone scans CT / MRI Bone culture and bone biopsy (Gold standard) Swab cultures 79. Treatment: Long term antiboitic use for 4-6 weeks even upto 6months. Spectrum kept broad at first, then narrowed based onbone culture sensitivities. Bone curettage during biopsy taking. 40% cases still need amputation. 80. CHRONICINFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS 81. C: ONCHOMYCOSIS (TENIA UNGUIUM) Infected nails appear thickened and discolored Nail eventually separates from nail bed. Nail appear flaky. Causes: Trichophyton rubrum most common Candida albicans usually in diabetics. Fungal cultures always obtained prior to antifungaltherapy. 82. Trichophyton rubrum responds best to oralTerbinafine. Candida can be treated with; Topical nystatin Miconazole Oral ketoconazole Itraconazole Griseofulvin. Removal of nail plate may imporve response for extensively involved nails. 83. CHRONICINFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS 84. D: VIRAL INFECTIONS Warts are viral infections caused by Human Papilloma Virus (HPV). Types of warts;1. Verruca vulgaris 95% Rough Raised cauliflowerlike appearance.2. Verruca plana 5% Smooth Minimally elevated. 85. Treatment options; 1. Keratolytic 70% success rate Duration several days to several weeks Salicylic acid preparations 2. Cryotherapy Liquid nitrogen Without anesthesia Warts refractory to conservative management. 86. 4. Surgical exicision Excised with atleast 1mm margin.5. Laser ablation.6. Electrocautery7. Intralesional bleomycin or 5-flourouracil 87. CHRONICINFECTIONS: A. CHRONIC PARONYCHIAB. OSTEOMYELITISC. ONCHOMYCOSISD. VIRAL INFECTIONSE. MYCOBACTERIAL INFECTIONS 88. E: MYCOBACTERIALINFECTIONS Typically uncommon Typical (Tuberculosis) Mycobacterial Infections Atypical Mycobacterial Infections. MYCOBACTERIUM MARINUM