Hand and Wrist Surgery - part 2 doc

I N F E C T I O N S 42 PEARLS • Early diagnosis followed by early antibiotic and surgical intervention • Adequate drainage of infection • Appropriate antibiotic management based on cultures PITFALLS • Necrotic tissue removal necessary • Complications result from inadequate drainage of infection 8 Supporative Flexor Tenosynovitis John C. P. Floyd and Waldo E. Floyd III His tory and Clin ical Presentati on A 52-year-old insulin-dependent diabetic man presented to his primary care physician 4 days after sustaining a palmar stab wound while sharpening a knife. Due to swelling and erythema about the wound overlying the palmar aspect of the fourth metacarpophalangeal joint, the patient was admitted to the hospital and placed on parenteral cefazolin. Significant medical history included insulin- dependent diabetes mellitus, peripheral vascular disease, and coronary artery disease. Bilateral above the knee amputations, multiple coronary artery bypass grafts complicated by wound healing problems, and drug allergies to vancomycin, sulfa, doxycycline, clindamycin, and ceftazidime characterized his medical history. The patient had undergone a limited incision and drainage procedure by an or- thopedic surgeon in the palmar wound just proximal to the A-1 pulley. The flexor tendons were reported to have been intact. Purulent fluid had been expressed from a rent in the flexor tendon sheath. The sheath was further incised and irrigated through a pediatric feeding tube. Purulent material was obtained for cultures and sensitivities. Despite oral amoxicillin management, purulent drainage and erythema persisted, prompting hand surgery referral. Phy sic al Examination On presentation to the hand surgeon, the palmar wound was draining serous fluid and there was no flexor tendon function (Fig. 8–1). Flexor tendons were visible within the wound, with a significant amount of surrounding nonviable tissue. Fur- ther surgical intervention was deemed appropriate. Dia gno stic Studies Anteroposterior and lateral radiographs of the left hand were positive for arterial calcification and soft tissue swelling. Dif feren tia l Di agn osi s Posttraumatic nonspecific inflammation Cellulitis Pyogenic, fungal, or mycobacterial infection Flexor tendon sheath infection with rupture of the flexor tendons Septic arthritis Osteomyelitis Foreign body S U P P O R A T I V E F L E X O R T E N O S Y N O V I T I S 43 Dia gno sis The diagnosis was flexor tendon rupture secondary to suppurative flexor tenosynovitis. Kanavel outlined the four classic, cardinal signs of digital flexor tenosynovitis: (1) fusiform digital swelling, (2) semiflexed digital posture, (3) significant pain associated with passive extension of the digit, and (4) exquisite tenderness along the A B Figure 8–1. (A) Ongoing palmar drainage and lack of wound healing following limited palmar drainage of suppurative ring finger flexor tenosynovitis. (B) Due to rupture of necrotic flexor tendons, the digit rested in full extension, rather than the characteristic semiflexed posture of flexor tenosynovitis. I N F E C T I O N S 44 Kanavel's Four Signs of Flexor Tendon Sheath Infection Diffusely swollen finger Interphalangeal joints rest in flexion Increased pain  with passive  digital extension Pain to palpation over flexor tendon sheath  Figure 8–2. Kanavel’s cardinal signs of suppurative digital flexor tenosynovitis are (1) fusiform digital swelling, (2) semiflexed digital posture, (3) pain with passive digital extension, and (4) pain along the flexor tendon sheath. Pain with passive digital extension is the earli- est and most sensitive sign. entire flexor tendon sheath (Fig. 8–2). All four signs are present in an advanced case and a combination of one or more signs is found in less severe cases. However, in this case, the semiflexed posture was not present as the flexor tendons had ruptured secondary to the advanced process. High-dose parenteral antibiotic management should be instituted at the time of diagnosis and continued postoperatively. Cultures and sensitivities guide the choice of antibiotic management. An infectious disease specialist best manages complex antibiotic therapy. The risk of infections in high-risk individuals should play an important part in the diagnosis. Diabetes and peripheral vascular disease are associated with hand infections refractory to medical intervention. To prevent the serious se- quelae of suppurative flexor tenosynovitis, the treating physician must maintain a high index of suspicion for this diagnosis. Adequate drainage of the flexor tendon sheath and removal of necrotic tissue were necessary. Surgical Management The transverse, open, draining, palmar wound was extended proximally ulnarward and distally radially, and full-thickness flaps were elevated. The flexor tendons were confirmed to be ruptured, and the edges of the tendons were quite friable. There was no frank pus present. With pressure over the palmar aspect of the digit, serous fluid could be expressed from the tendon sheath. The necrotic flexor tendons had become a protected focus of infection, necessitating their excision. With ring finger flexion, the distal tendons could be delivered into the palmar wound. An ulnar midaxial incision was begun distally at the level of the digital whorl and carried back to the ulnar midaxial line at the distal interphalangeal joint level and back to the ulnar midaxial line at the proximal interphalangeal joint level. Subcutaneous tissue was divided and a full-thickness volar flap was elevated containing the neurovascular bundles. The flexor tendon sheath was opened proximally distal to the A-4 pulley. The profundus was divided distal to the A-4 pulley and was completely excised. The flexor superficialis was divided at its insertion and was completely excised. Aerobic and anaerobic cultures were obtained. The digital and palmar incisions were loosely approximated, leaving the transverse wound open. The wounds were dressed and a volar splint was applied, immobilizing the wrist in slight dorsiflexion. Postoperative Manag ement The patient’s postoperative care consisted of daily dressing changes and whirlpool therapy. Due to the patient’s multiple drug allergies, no parenteral antibiotics were S U P P O R A T I V E F L E X O R T E N O S Y N O V I T I S 45 administered. Cultures were positive for Staphylococcus aureus susceptible to vancomycin, gentamicin, rifampin, Bactrim, and tetracycline. Infectious disease con- sultation was obtained. Two weeks postoperative, wounds were healing well with no evidence of active infection. As the protected focus of nonviable flexor tendon tissue had been removed, the decision was made in this complex case not to proceed with a vancomycin desensitization program. The surgical approach, independent of further antibiotic administration, resulted in healing and resolution of the infectious process. Once the infection began to abate, a lighter dressing to enable early motion replaced the splint. Following wound healing, resolution of infection, recovery of passive motion, and the development of tissue equilibrium, delayed flexor tendon reconstruction may be considered in such cases. Alternat ive Methods of Management Selected early cases of flexor tenosynovitis may be managed with parenteral in- travenous antibiotics, splinting of the hand in the functional position, and eleva- tion. In early cases, Kanavel’s signs are limited to pain with passive digital extension. More advanced cases are characterized by the additional findings of a semiflexed digital posture and pain along the entire flexor digital sheath. Significant improve- ment must occur within 24 hours with complete resolution of presenting signs by 48 hours. Patients initially presenting with all four of Kanavel’s signs demand more urgent surgical intervention. Closed tendon sheath irrigation is an excellent surgical management technique, which should be instituted early in severe cases and in those less severe cases that do not quickly respond to intensive antibiotic management. This technique re- quires a zigzag incision in the palm proximal to the A-1 pulley of the involved digit. At the proximal margin of the A-1 pulley, the flexor tendon sheath is excised, and cultures are obtained. A second incision is made in the midaxial line over the distal portion of the middle digital segment sheath distal to the A-4 pulley. A long 16- or 18-gauge flexible catheter is directed from the A-1 pulley into the flexor sheath for a distance of up to 1.5 to 2 cm. A small rubber drain is directed from the distal wound to beneath the A-4 pulley proximally. Following proximal wound closure around the catheter, the system is tested for patency by flushing the catheter with sterile saline and observing the effluent from the distal wound/drain. The hand is then immobilized with a splint secured by a soft dressing with the catheter and drain exposed. Postoperatively the sheath is con- tinuously or intermittently flushed with saline. After 24 hours, if the signs of infection have resolved, then the catheter and drain are removed and mobiliza- tion begun. Complications The most important method for prevention of further complications is adequate drainage. If inadequate drainage occurs, adhesions, tendon rupture, and osteomyelitis can result. The use of antibiotic treatment in combination with inadequate drainage can result in the development of resistant organisms. I N F E C T I O N S 46 Suggested Readings Burkhalter WE. Deep space infections. Hand Clin 1989;5:553–559. Floyd WE III, Troum S, Frankle MA. Acute and chronic sepsis. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. 1st ed. New York: McGraw-Hill; 1996:1741. Glass KD. Factors related to the resolution of treated hand Infections. J Hand Surg 1982;7A:388–394. Kanavel AB. Infections of the Hand: A Guide to the Surgical Treatment of Acute and Chronic Suppurative Processes in the Fingers, Hand, and Forearm. Philadelphia: Lea & Febiger; 1912. Kanavel AB. Infections of the Hand. 7th ed. Philadelphia: Lea & Febiger; 1943. Mann RJ, Peacock JM. Hand infections in patients with diabetes mellitus. J Trauma 1977;17:376–380. McGrath MH. Infections of the hand. In: May JW, Littler JW, eds. Plastic Surgery. Philadelphia: Saunders; 1990:5529–5556. Neviaser RJ. Closed tendon sheath irrigation for pyogenic flexor tenosynovitis. J Hand Surg 1978;3A:462–466. Neviaser RJ. Tenosynovitis. Hand Clin 1989;5:525–531. Neviaser RJ. Infections. In: Green DP, ed. Green’s Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone; 1993:1021–1038. Stern PJ, Staneck JL, McDonough JJ, et al. Established hand infections: a con- trolled prospective study. J Hand Surg 1983;8A:553–559. H E R P E T I C W H I T L O W 47 Figure 9–1. Grouped vesicular lesions of the index finger. 9 Herpetic Whitlow Kevin D. Plancher His tory and Clin ical Presentati on A 23-year-old nursing student, working in the intensive care unit for the first time, treated a patient without gloves. The patient reported symptoms of pain and burning or tingling of the infected digit. Erythema and edema followed with the development of vesicles on an erythematous base over the next 7 to 10 days. These vesicles are filled with clear or cloudy fluid. Phy sic al Examination On examination, the patient’s finger is tender and edematous. Unlike a felon, the pulp space is not swollen. Examination revealed grouped vesicular lesions, which progressed to ulcers at 2 weeks (Fig. 9–1), and extension of the infection into sub- ungual space and lymphangitic streaking was found. In the following 7 to 10 days the vesicles dried and began to heal (Fig. 9–2, different patient). Dia gno stic Studies Diagnosis of herpetic whitlow is usually based on clinical presentation. The diagnosis can be confirmed with a Tzanck smear, which reveals characteristic multi- nucleated giant cells. Other smears, stains, and serologic tests can be used for diagnosis of primary infections. Herpes antibody titers can also be used to confirm the diagnosis. Figure 9–2. In the following 7 to 10 days the vesicles dry and begin to heal. I N F E C T I O N S 48 Dif feren tia l Di agn osi s Cellulitis Felon Paronychia Pyogenic infections Dia gno sis Herpetic Whitl ow of the Index Fing er Diagnosis of herpetic whitlow is usually based on presentation of the affected digit with the characteristic lesions and the patient’s history. In health care workers (den- tists, dental hygienists, nurses, physicians), infection is usually due to exposure to infected oropharyngeal secretions of patients (herpes simplex virus type 1). This can easily be prevented by use of gloves and by scrupulous observation of universal fluid precautions. In the general adult population, herpetic whitlow is most often due to autoinoculation from genital herpes; therefore, it is most frequently secondary to infection with herpes simplex virus type 2 (HSV-2). Infection involving the finger usually is due to autoinoculation from primary oropharyngeal lesions as a result of finger-sucking or thumb-sucking behavior in patients with herpes labialis or herpetic gingivostomatitis. Care should be taken as viral shedding may occur for another 12 days and the lesions may be infective. The paronychial region should be examined for abscesses indicating a concomitant pyogenic infection. The oral cavity should be examined for preexisting herpetic lesions. Herpetic whitlow may be accompanied by axillary and epitrochlear adenopathy with lymphangitis of the forearm. Nonsurgical Managemen t The infection resolves spontaneously in 2 to 3 weeks and treatment is directed to- ward the patient’s symptoms relief. In primary infections, topical acyclovir 5% has been demonstrated to shorten the duration of symptoms and viral shedding. Oral acyclovir may prevent recurrence. Use antibiotic treatment only in cases complicated by pyogenic infections or bacterial superinfections. Surgical Techni que In most cases, surgical treatment is not recommended and if undertaken, it can lead to bacterial superinfection, viremia, and encephalitis. In rare instances, with an abscess and concomitant pyogenic infections, surgical incision and drainage may be warranted. Suggested Readings Gill MJ, Arlette J, Buchan K. Herpes simplex virus infection of the hand. A profile of 79 cases. Am J Med 1988;84:89–93. Haedicke GJ, Grossman JA, Fisher AE. Herpetic whitlow of the digits. J Hand Surg 1989;14B:443–446. PEARLS • Distinguishing between a felon and herpetic whitlow is important, because incision and drainage is contraindicated for herpetic whitlow. • Splint and elevate • Level of suspicion is high in dental personnel PITFALLS • Surgical treatment can lead to bacterial superinfection, viremia, and encephalitis. • Do not undertake irrigation and debridement unless bacterial infection warrants treatment. H E R P E T I C W H I T L O W 49 Hurst LC, Gluck R, Sampson SP, Dowd A. Herpetic whitlow with bacterial abscess. J Hand Surg 1991;16A:311–314. Klotz RW. Herpetic whitlow: an occupational hazard. AANA J 1990;58:8–13. McNicholl B. Recurrent herpetic whitlow. Arch Emerg Med 1990;7:124–125. Smith E, Hallman JR, Pardasani A, McMichael A. Multiple herpetic whitlow lesions in a patient with chronic lymphocytic leukemia. Am J Hematol 2002;69:285–288. Walker LG, Simmons BP, Lovallo JL. Pediatric herpetic hand infection. J Hand Surg 1990;15A:176–180. Weisman E, Troncale JA. Herpetic whitlow: a case report. J Fam Pract 1991;33: 516,520. I N F E C T I O N S 50 Tendon Capsule A B PEARLS • Open lavage with adequate debridement to avoid complications. • Early intervention to avoid collar button abscess • Appropriate immediate antibiotic coverage • Must evaluate the wound in the same position as the injury occurred to appreciate the depth PITFALLS • Undertreatment with closure of wound seen after 8 hours from injury • Underestimation of full depth of penetration to wound and joint Figure 10–1. (A) Tooth from bite severing skin and entering metacarpophalangeal (MP) joint of the hand. (B) Although the wound looks small and innocuous, when the digit is in extension the penetration is much deeper. Adequate debridement and opening of the wound are essential. 10 Bites to the Hand Kevin D. Plancher His tory and Clin ical Presentati on A 17-year-old college student presented to the emergency room with an open wound to the dorsum and a piece of human tooth in the wound. The patient reported he had been in a bar brawl last evening. Closed fist injuries are encountered almost ex- clusively in young males, usually occurring during adolescence through the fourth decade of life. Although toddlers are notorious for biting each other, these injuries tend to be superficial and low risk. [...]... surfaces of the hand are the result of a direct and deliberate (“chomping”) human 51 INFECTIONS Figure 10 2 Unusual presentation of a human bite of the ulna aspect of the hand affecting the 5th volar MP bite (Fig 10 2) The most common site of injury is the third and fourth digits at the metacarpophalangeal joint Osteochondral fractures are common Bite wounds to the hand may cause cellulitis and abscess... Diagnosis Puncture wound Insect bite Other animal bite Marine animal bite Diagnosis Human Bite to the Hand There are two major mechanisms of human bites to the hand An example of penetrating trauma is a closed fist injury, in which one person strikes another in the mouth, causing a fight bite to the hand If the hand is clenched in a fist, laceration of the skin over the knuckle may damage a tendon sheath or... abscess Human bite wounds are particularly virulent because of the gram-positive and anaerobic bacteria present in the mouth Nonsurgical Management Patients who present less than 1 day following injury may not have signs of sepsis, and wound exploration and swabbing for aerobic and anaerobic cultures to determine antibiotic treatment may be sufficient Treatment includes antibiotics and close observations... drainage and irrigation may be necessary A wide-open incision should be used for the irrigation and debridement Several liters should be used in the irrigation This is followed by close observation in the hospital and IV antibiotics Frequently the tooth will penetrate the metacarpophalangeal joint where the cartilage is particularly sensitive to infection Every puncture wound near the proximal 52 ...BITES TO THE HAND Physical Examination If the bite results in a puncture wound that is swollen, red, and painful, the wound is likely to be infected Patients with infection may have an elevated temperature, swollen glands, or a history of fever Any loss of motion or sensation in the fingers suggests that a tendon or... injuries often result in injury to the extensor tendon and its sheath When a closed fist injury occurs to someone with a clenched fist, the bacterial load is often carried back into the hand as the tendon slides back to its relaxed state (Fig 10–1) This means that the problem of contamination cannot be easily resolved using normal methods of irrigating and cleaning a wound Patients who present with dog... present with dog or cat bites have a wounded area that is painful, red, and swollen Abscess formation may develop Diagnostic Studies Wound cultures are used to diagnose the infecting organisms Aerobic and anaerobic cultures should be included For human bites, the most common infecting organisms include Staphylococcus aureus, streptococci, and Eikenella corrodens For cat bites, cultures should be examined... be examined for Pasteurella multocida For dog bites, Straphlococcus aureus, Streptococcus viridans, Bacteroides spp., and P multocida may be cultured All patients with lacerations over the metacarpophalangeal joint should be x-rayed for retained teeth fragments, regardless of patient-reported history Radiographs are used to exclude fractures or foreign bodies (e.g., teeth) Radiographs can be used to... wound after that time should be left open Close observation in all cases must be performed Antibiotics recommended may include penicillin G, ampicillin, carbenicillin, or tetracycline for E corrodens, and a cephalosporin for Staphylococcus organisms For dog bites, most suspected organisms are sensitive to penicillin Tetanus prophylaxis should also be included with the use of antibiotics in dog bite . treated hand Infections. J Hand Surg 19 82; 7A:388–394. Kanavel AB. Infections of the Hand: A Guide to the Surgical Treatment of Acute and Chronic Suppurative Processes in the Fingers, Hand, and Forearm hand from dog bites. J Hand Surg 20 00 ;25 B: 26 28 . Griego RD, Rosen T, Orengo IF, Wolf JE. Dog, cat, and human bites: a review. J Am Acad Dermatol 1995;33:1019–1 029 . Hausman MR, Lisser SP. Hand. Mycobacterium asiaticum. J Hand Surg [Am] 1998 ;23 A:756. Gunther SF, Elliott RC, Brand RL, Adams JP. Experience with atypical mycobacterial infection in the deep structures of the hand. J Hand Surg [Am] 1977 ;2: 90–96. Gunther

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