Overview of hand infections
- Sandeep Sebastin, MMed, FAMS
Sandeep Sebastin, MMed, FAMS
- Consultant, Department of Hand & Reconstructive Microsurgery
- National University Hospital, Singapore
- Kevin C Chung, MD, MS
Kevin C Chung, MD, MS
- Chief of Hand Surgery
- Charles B.G de Nancrede Professor of Surgery
- University of Michigan Health System
- Shimpei Ono, MD, PhD
Shimpei Ono, MD, PhD
- Assistant Professor
- Department of Plastic, Reconstructive, and Aesthetic Surgery
- Nippon Medical School
- Section Editors
- Charles E Butler, MD, FACS
Charles E Butler, MD, FACS
- Section Editor — Plastic and Reconstructive Surgery
- The University of Texas, MD Anderson Cancer Center
- Marc G Jeschke, MD, PhD
Marc G Jeschke, MD, PhD
- Section Editor — Burn Surgery
- Director Ross Tilley Burn Centre
- Sunnybrook Health Sciences Centre
- Professor, Department of Surgery and Plastic Surgery
- University of Toronto
Infections of the upper limb are common and account for up to 35 percent of patients admitted to a hand surgery service. The majority of patients with acute hand infections are healthy and active young adults who have either neglected or appropriate, but delayed, treatment for minor trauma . More severe infections with significant morbidity are seen in patients with impaired immune status.
Early and superficial infections of the hand may respond to nonsurgical management; however, most hand infections are surgical emergencies. Prompt evaluation and proper treatment of hand infections can mean the difference between an excellent outcome and permanent disability.
INITIAL EVALUATION AND MANAGEMENT
The initial evaluation and management of a hand infection includes a focused history and examination, and often involves laboratory evaluation and imaging. The area of erythema should be marked to help document progression of the infection. Elevation of the hand and arm and application of a heat pack, along with appropriate pain control, will decrease swelling and provide comfort. Empiric antibiotics should be started. These measures are discussed below.
History — A focused medical history should determine the possible source of infection, progress of the infection, the immune status of the patient, and any relevant past medical history:
●Symptoms ─ The onset of pain, loss of function, fever and/or chills, and any spontaneous drainage should be documented. Severe throbbing pain is suggestive of an abscess in a confined space. A rapid deterioration in general condition is suggestive of severe infections like necrotizing fasciitis and gas gangrene. (See 'Necrotizing fasciitis' below and "Necrotizing soft tissue infections".)
- Tosti R, Ilyas AM. Empiric antibiotics for acute infections of the hand. J Hand Surg Am 2010; 35:125.
- O'Malley M, Fowler J, Ilyas AM. Community-acquired methicillin-resistant Staphylococcus aureus infections of the hand: prevalence and timeliness of treatment. J Hand Surg Am 2009; 34:504.
- McDonald LS, Bavaro MF, Hofmeister EP, Kroonen LT. Hand infections. J Hand Surg Am 2011; 36:1403.
- Griego RD, Rosen T, Orengo IF, Wolf JE. Dog, cat, and human bites: a review. J Am Acad Dermatol 1995; 33:1019.
- Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop Relat Res 1987; :237.
- Canales FL, Newmeyer WL 3rd, Kilgore ES Jr. The treatment of felons and paronychias. Hand Clin 1989; 5:515.
- Jebson PJ. Infections of the fingertip. Paronychias and felons. Hand Clin 1998; 14:547.
- Hochman LG. Paronychia: more than just an abscess. Int J Dermatol 1995; 34:385.
- Linscheid RL, Dobyns JH. Common and uncommon infections of the hand. Orthop Clin North Am 1975; 6:1063.
- Stern PJ. Selected acute infections. Instr Course Lect 1990; 39:539.
- Watson PA, Jebson PJ. The natural history of the neglected felon. Iowa Orthop J 1996; 16:164.
- Haedicke GJ, Grossman JA, Fisher AE. Herpetic whitlow of the digits. J Hand Surg Br 1989; 14:443.
- Louis DS, Silva J Jr. Herpetic whitlow: herpetic infections of the digits. J Hand Surg Am 1979; 4:90.
- Boles SD, Schmidt CC. Pyogenic flexor tenosynovitis. Hand Clin 1998; 14:567.
- Neviaser RJ. Tenosynovitis. Hand Clin 1989; 5:525.
- Kanavel A. Infections of the hand. In: A guide to the surgical treatment of acute and chronic suppurative processes in the fingers, hand, and forearm, 7th ed, Lea & Febiger, Philadelphia, PA 1939.
- Burkhalter WE. Deep space infections. Hand Clin 1989; 5:553.
- Jebson PJ. Deep subfascial space infections. Hand Clin 1998; 14:557.
- Freeland AE, Senter BS. Septic arthritis and osteomyelitis. Hand Clin 1989; 5:533.
- Murray PM. Septic arthritis of the hand and wrist. Hand Clin 1998; 14:579.
- Gonzalez MH. Necrotizing fasciitis and gangrene of the upper extremity. Hand Clin 1998; 14:635.
- Dellinger EP. Severe necrotizing soft-tissue infections. Multiple disease entities requiring a common approach. JAMA 1981; 246:1717.
- Stone DR, Gorbach SL. Necrotizing fasciitis. The changing spectrum. Dermatol Clin 1997; 15:213.
- Giuliano A, Lewis F Jr, Hadley K, Blaisdell FW. Bacteriology of necrotizing fasciitis. Am J Surg 1977; 134:52.
- INITIAL EVALUATION AND MANAGEMENT
- Clinical examination
- Laboratory evaluation
- - Plain films
- - Ultrasound
- Outline the area of erythema
- Antibiotic therapy
- BITE WOUNDS
- Animal bites
- Human bites
- SUPERFICIAL HAND INFECTIONS
- Pulp space infections
- Herpetic whitlow
- Subcutaneous abscess
- Web space abscess
- DEEP INFECTIONS
- Synovial space infections
- Deep fascial space infections
- Septic arthritis
- Necrotizing fasciitis
- MYCOBACTERIAL INFECTIONS
- MIMICKERS OF ACUTE HAND INFECTIONS
- Acute calcific tendinitis
- Retained foreign bodies
- Chemotherapeutic infiltration
- Pyoderma gangrenosum
- Metastatic tumor
- SUMMARY AND RECOMMENDATIONS