Common Hand Injuries Common Hand Infections. Braemar Hospital GPCME 1 November 2014

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1 Common Hand Injuries Common Hand Infections Braemar Hospital GPCME 1 November 2014

2 Waikato Hospital Tristram Clinic, 200 Collingwood Street, Hamilton P F E appts@tristramclinic.co.nz Tauranga Hospital Da Vinci Clinic, 727 Cameron Road, Tauranga P F E brandon@davinciclinic.co.nz

3 Overview General Principles Common Hand Infections Nail and pulp Tendons and deep palm Bites Common Hand Injuries Nail and pulp Distal phalanx fractures Metacarpal fractures

4 General Principles Hands are resistant to infection - is the patient immunosuppressed? Oedema HANDS SWELL!! Drainage of collections Cultures Immobilisation in safe position Elevation Tetanus Antibiotics

5 Acute Paronychia Commonest infection in hand Infection of nail fold Edge of nail fold red and tender Staph Aureus commonly

6 Paronychia Treatment Non surgical in early stages Cover staph aureus eg Flucloxicillin Moderate cases Ring Block Elevate nail fold off the nail plate Preserve the nail Severe Cases or any case with pus under the nail Ring block Remove part or all of the nail Incision parallel to the epoychium

7 Chronic Paronychia Chronic maceration and obstruction of fold Wet work + diabetics Scrapings, culture Candida albicans Topical steroids and anti fungals Diligent finger hygiene Trial of nail preservation

8 Chronic Paronychia Recurrent or resistant chronic paronychia Nail plate removal Topical and oral antifungal treatment Eponychial marsupialisation (Keyser and Eaton)- epithelialsition

9 Felon Subcutaneous abscess in distal pulp of finger or thumb Why are felons so painful? What are the common mechanisms? What bacteria cause felon?

10 Felon Treatment Surgical drainage Ring block Incision of lateral aspect of the pulp Parallel to the nail Mid axial line Never a fish mouth

11 Suppurative flexor tenosynovitis Penetrating injury Painful Red Swollen finger Pain with passive stretch Whole finger redness

12 Tendon Sheath Infection Suppurative Tenosynovitis Tendon sheath is a closed compartment Relatively immune protected area Untreated infection can destroy the tendon within hours

13 Flexor Sheath Mid distal phalanx to distal palmar crease May connect to adjacent finger s sheath May connect to carpal tunnel

14 Kanaval s Signs of Tenosynovitis Partially flexed finger Tenderness over flexor tendon sheath Differentiates tendon sheath infection vs. septic joint Pain with passive extension 4 th ADDED LATER Fuisiform swelling of finger Allen B. Kanaval, Prof. Of Surg. NorthWestern Univ. Chicago 1912 Mortality in 1912 from hand infection with ascending lymphangitis was upto 30%

15 Tenosynovitis Treatment Surgical drainage open and irrigate Elevation Splinting I.V. Abs - Flucloxicillin Complications Necrosis of tendon Extension to forearm Median nerve compression Septic shock

16 Deep potential space infections Web space Mid-palmar space Thenar space Space of Parona

17 Web space abscess Abscesses may form in the loose tissue of the webspaces and discharge volarly, dorsally or both A collar button abscess describes two pockets of pus connected by a narrow isthmus

18 Palmar Space Infections Anatomy mid palmar and thenar spaces

19 Bites Human bite Dog bite Cat bite

20 Human bite Crush Abrasion Bruising Cellulitis Punch = fight bite Unreliable history Suspect deep injury

21 Human bite Wide range of bacteria Aerobic and anaerobic Most common are Gram positive cocci Eikenella corrodens Gram -ve bacillis Sensitive to beta lactam antibiotics Eg Amoxicillin / Clavulonic acid Second line Cotrimoxazole + Metronidazole Clindamycin

22 Cat bite Sharp Puncture wounds Most common Gram Positive Cocci Pasturella maltocida Gram negative Sensitive to Amoxicillin Irrigate Dress don't suture

23 Dog bite 1 bite per 50 dogs per year in NZ Crushing Tearing injuries Tissue loss Fractures Gram positive cocci

24 Animal Bites Penetrating innoculum Look for teeth on Xrays Excise edges of wounds and clean Cats Pasturella Multocida Augmentin recommended

25 Farm yard infections Increased anaerobes Clostridium perfringens Benzyl-Penicillin or Metronidazole

26 Magic Words Collection requiring drainage Suspected tenosynovitis Diabetic Failed trial of oral antibiotics Tissue loss Heavily contaminated Human bite

27 Common Hand Injuries

28 Nail and pulp injuries Subungal haematoma Nail bed laceration Finger tip amputation or near amputation

29 Nail and finger tip anatomy

30 Subungal haematoma Crush injury Painful Treatment? Investigations? Referral?

31 Nail bed laceration Crush injuries +/- underlying fractures Split periosteum exposes bone / fracture Toddlers Siblings Doors Suspect growth plate fractures in children

32 Nail bed laceration Lacerations are repaired with dissolving sutures (vicryl rapid) Nail is removed for access to nail bed Lacerations across the nail fold are more complex Abrasions heal by secondary intention Nail bed scarring may lead to splitting or separation of the nail Early nail separation can be treated with nail bed grafts from toes

33 Finger tip amputation

34 Classification

35 Principles Define the defect Replace like with like Maintain length Skeletal stability Durable padded cover Restore sensation Early mobilisation Expeditious, simple & reliable Cosmesis Tailored to the patient

36 Reconstructions Primary closure / terminalisation Secondary intention - Dressings Grafts Local flaps Homodigital Heterodigital Distal flaps

37 What can be dressed? 1/3 of the pulp = size of nail No exposed bone No Fracture Dress with semi-permeable dressings eg IV3000 Change as needed 2-3 days

38 Atasoy flap, 1970

39 Cross finger flap, 1951

40 Distal phalanx fractures A fracture is a soft tissue injury associated with disruption of the bone

41 Neck of the distal phalanx

42 Tuft fracture

43 Fracture disrupting the extensor insertion

44 Fracture disrupting the flexor insertion

45 Metacarpal Fractures

46 Not all fractures need fixation

47 Thumb metacarpal Intrinsically unstable Isolated from other supporting bones Fractures of the base (Bennett s, Rolando s) involve the CMC joint and the APL tendon Require anatomic reduction and immobilisation Frequently require fixation to immobilise

48 Finger Metacarpals Intrinsically stable Supported by adjacent bones and intrinsic muscles Length and alignment needs to be adequate to allow a natural cascade of the fingers A moderate degree of flexion at the fracture site is permissible while retaining good hand function Rotation is an indication for reduction

49 Degree of flexion Index metacarpal: 5-10 degrees Middle metacarpal: degrees Ring metacarpal: degrees Little metacarpal: degrees

50 Indications for intervention Compound Fractures Fractures involving the joint Any rotation causing fingers to cross over Multiple metacarpal fractures Severe flexion Moderate flexion where dorsal hand and knuckle are deformed

51 Managing a metacarpal X-ray to confirm fracture orientation Haematoma block 10mL of 1% lignocaine or 0.75% ropivocaine Manipulation and ulnar gutter spint MCPJ flexion IPJ extension Confirm reduction Rpt X-rays in 1 week

52 Magic Words Compound Tissue loss Avulsion Amputation Not perfused Rotated Unstable

53 Waikato Hospital Tristram Clinic, 200 Collingwood Street, Hamilton P F E appts@tristramclinic.co.nz Tauranga Hospital Da Vinci Clinic, 727 Cameron Road, Tauranga P F E brandon@davinciclinic.co.nz

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