The Weekly Probe. June 26, 2012 Volume 15 Issue 19

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1 EMERGENCY MEDICINE Liverpool Hospital The Weekly Probe June 26, 2012 Volume 15 Issue 19 THIS WEEK; 1. Hand Infections 2. Nail Root Dislocation 3. Next Week s Case 4. Joke / Quote of the Week HAND INFECTIONS Last week we saw a 25-year-old gym instructor who presented with pain and swelling over the volar aspect of the right palm 4 days after a palm frond punctured and broke off into his palm which he was unable to remove himself. He was febrile and had local tenderness over this area with loss of the concavity of his palm. He was referred to the plastic surgery service for drainage of his palmar space, and removal of the palm frond. We reviewed this topic 3-4 years ago but it s worth repeating. This is based on a review article in Surgery 23(1);19-25 by McNab. The important points from an emergency perspective are summarized below. Our main concern with hand infections is that they are common, and can rapidly progress to become established and inaccessible to antibiotics in the deep spaces of the hand, leading potentially to long term disability. Causative organisms can be predicted by the type of injury, location and source of infection and patient s co-morbidities; Aerobic organisms predominate (65%) with S. aureus being the most common (35%). Think about gram negative organisms in contaminated wounds or immunosuppressed patients. History; Mechanism Duration of symptoms Medical co-morbidities Tetanus status Examination; Systemic signs of sepsis Local signs (swelling, warmth, tenderness, lymphadenitis, lymphangitis Abscess formation (throbbing pain, sleep disturbance) Fluctuance of the dorsum of the hand (dorsal abscess, local oedema or palmar abscess as lymphatics drain to the dorsal surface of hand) Investigations; X-ray s (foreign bodies, fractures, osteomyelitis) Fluid or tissue for microbiology CBC, CRP, Blood Cultures

2 Treatment Check tetanus status (ADT +/- immunoglobulin) Empirical antibiotics, then guided by microbiology Immobilise hand (POSI splint) Elevate Limb Early surgical intervention for incision, drainage and washout of abscesses Initial Empiric Antibiotics; 1) Simple laceration (irrigation with no antibiotics) 2) Wound infections / Cellulitis (Flucloxacillin or cephazolin) 3) Septic arthritis / lightly contaminated (cephalosporin or vancomycin and gentamicin) 4) Severe contamination (cephalosporin, gentamicin, metronidazole) 5) Suspected drug resistant organism (vancomycin) Felon Subcutaneous abscess in the distal pulp of the digit. (see diagram below points M, N) Often a history of trauma. The infection breaks down the septa and causes skin necrosis / sinus formation. Can extend into the bone, interphalangeal joint or flexor sheath. Two ways to drain longitudinal over abscess or along the side of the pulp (not commonly used due to interference with digital nerve & loss of sensation) Needs antibiotics and specialist follow-up if not requiring inpatient admission. Pyogenic Flexor Tendosynovitis Kanavels Signs Flexed finger position Symmetrical finger swelling Tenderness along sheath Pain on passive extension Leads to adhesions or tendon necrosis with loss of function. Synovial sheaths of 2-4 th don t extend into the palm, whereas the 1 st and 5 th do. Treatment with antibiotics, splintage, elevation of limb and surgical drainage.

3 Paronychyia / Eponychia Paronychia is an infection along the lateral border of the nail. Eponychia is an infection which extends to the eponychium in the proximal part of the nail. (Point E) Early infection can be treated with warm soaks, oral antibiotics, rest and elevation. Superficial abscess can be drained by running a blunt probe under the fold. Extensive infections will need removal of adjacent nail. Web Space Infections Pain and swelling is localised to the web space and distal palm. The neighbouring fingers are abducted from each other. Significant infections need drainage. Palmar Space Infections There are 2 deep spaces in the hand (midpalmar and thenar spaces) which lie deep to the flexors & lumbricals, and superficial to the interossei. They are limited proximally by the carpal tunnel. 2 compartments are separated by a septum which runs down to the 3 rd metacarpal. Clinically the palm flattens, and the dorsum of the hand swells due to the direction of the lymphatic drainage. There is also pain, swelling and tenderness over the involved space. Treatment is similar to other hand infections antibiotics, immobilise, elevate, surgical drainage.

4 Bites Wounds should not be closed initially Small wounds can be left to heal by secondary intention. Larger wounds should be packed after initial washout and debridement, and then undergo delayed closure at hours. Human Bites Most common injury is the fight bite with an injury over the MCPJ after the fist impacts with a tooth. Always refer these injuries to a hand specialist regardless of the size of the penetration. Antibiotic guidelines recommends prophylaxis with Augmentin, and if infection is established then Ceftriaxone & Metronidazole until sensitivities return. Animal Bites The organisms commonly seen in animal bites are Pasteurella species, Staphylococcus aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobes. Cat bites have a higher incidence of infection than dog bites. Unusual Infections to Consider (request specific cultures if suspected) Mycobacteria marinum (fish, fish-tanks or seawater) Mycobacterium avium-intracellulare (poultry via water and soil) causes cutaneous infections, arthritis and osteomyelitis Fungal (dishwashers, water exposure +++) chronic paronychia Sporotichosis (puncture wounds from thorns) Herpetic Whitlow (oral contact) similar to felon, absence of pus, soft pulp space, small vesicles surrounded by red wheals. Usually self limiting, aciclovir can relieve pain. Nocardia (puncture wound while gardening) cerebral and endocardial complications

5 Nail Root Dislocations 28-year-old man asks his wife to hammer a nail in whilst he is holding it- bad mistake. As shown below the proximal nail bed has been levered off the nail bed. What do we do? (Other than asking the wife to stop laughing). Occasional we see such patients who have caught the tip of the finger or toe in a door or under a weight such as a hammer causing a painful deformity. The base of the nail will be found resting above the eponychium instead of in its normal anatomical position beneath. The cuticular line that had joined the eponychium at the nail fold will remain attached to the nail at its original position this forms a constant landmark on the nail. If any nail is showing proximal to this landmark it indicates that the nail is not in its normal position beneath the eponychium. What to do: X-ray to rule out an underlying fracture. Anaesthetise the area using a digital block +/- procedural sedation Lift the base of the nail off the eponychium, and thoroughly cleanse and inspect the nail bed. Minimally debride loose cuticular tissue and test for a possible avulsion of the extensor tendon. If bleeding is a problem, establish a bloodless field using a latex glove to wrap and tourniquet the finger or use an arterial tourniquet (manual BP cuff or procedural arterial tourniquet). Consider repairing any nailbed lacerations with a fine absorbable suture like 7-0 or 6-0 Vicryl. Reinsert the root of the nail under the eponychium.

6 If the nail tends to drift out from under the eponychium, it can be sutured in place with two 4-0 nylon or polypropylene stiches in the corners. Any non-absorbable sutures should be removed after one week. Cover the area with a finger tip dressing and splint any underlying fracture. Provide tetanus prophylaxis. What not to do: Do not ignore the nail root dislocation and simply provide a fingertip dressing. This is likely to lead to continued bleeding or to a later infection because tissue planes have not been replaced in their natural anatomic position. Do not debride any part of the nailbed, sterile matrix or germinal matrix. Remember if in doubt, refer for specialist assessment. NEXT WEEKS CASE 65-year-old woman with a history of hypertension, IHD, CCF, morbid obesity and type 2 DM presents with dyspnoea. She is offloaded from the ambulance with a non-rebreather mask with saturations of 98%, RR30, BP 110/80. You are unsure whether this is CCF or CAL. What are you thoughts regarding the oxygen therapy? What is required? What is being given? What are the pros and cons the oxygen?

7 JOKE / QUOTE OF THE WEEK Some jokes for females next week some for the males He said to me I don't know why you wear a bra; you've got nothing to put in it I said to him you wear pants don't you? He said to me should we try swapping positions tonight? I said That s a good idea you stand by the stove, while I sit on the sofa and do nothing but fart. He said to me what have you been doing with all the grocery money I gave you? I said to him Turn sideways and look in the mirror! He said to me why don't women blink during foreplay? I said to him they don't have time. He said to me how many men does it take to change a roll of toilet paper? I said to him I don't know; it has never happened. He said to me why is it difficult to find men who are sensitive, caring and good-looking? I said to him they already have boyfriends. He said what do you call a woman who knows where her husband is every night? I said a widow. He said to me. Why are married women heavier than single women? I said to him Single women come home, see what's in the fridge and go to bed. Married women come home, see what's in bed and go to the fridge.