Hand infections need immediate attention

Originally published in The Ottawa Citizen May 18, 2004
Original Title: I’ve got blistahs on my fingahs

What are the common hand infections? What causes them and how are they treated?

Although by no means a comprehensive guide, there are five common infections encountered in the emergency room or your family doctor’s office.

The anatomy of the hand has many enclosed small spaces, each segregated from the other. This compartmentalization can foster local infections leading to significant damage within hours.

The location of the infection, underlying medical condition (e.g. diabetes, sexually transmitted disease or immune system deficiencies), intravenous drug use, tropical fish aquarium exposure, and type of injury (abrasion, laceration, burn, bite, crush or penetration) will dictate the approach to wound and infection care.

The basic approach for successful outcomes includes early splinting of the affected area, elevation of the hand above heart level, antibiotics and incision and drainage of abscesses, if present. Splinting and elevation can ease the pain and swelling and protect the infected area. A tetanus shot is usually required.

Your physician or nurse will irrigate and cleanse the wound if it is split open. Any dead or dying tissue will be removed (debrided) because it can promote infection.

A paronychia occurs when the top layer of skin bordering the fingernails is traumatized via a manicure, dishwashing, an ingrown nail, hangnail or thumb sucking in children.

It can cause localized redness, pain and swelling. If left untreated, an abscess can form that may drain pus from the wound’s edge.

An early measure to help prevent the infection’s progress is 20-minute hot water soaks three to four times a day for two to three days. Usually the water temperature should be equal to the individual’s maximum bearable range. The hot water creates a local temperature environment that is inhospitable to bacteria. Application of topical antibiotics like mupiricin (Bactroban) or fusidic acid (Fucidin) can help destroy the remaining bacteria. These two measures are sometimes all that is required to cure this infection.

Abscesses must be incised and drained. Severe paronychias may require an oral antibiotic.

Abscesses that form in the pad of the fingertip are called felons and commonly affect the thumb and index finger. It is caused by penetrating trauma from splinters, glass, abrasions and minor puncture wounds. The pain is severe and throbbing; much worse than a paronychia.

Sometimes if caught early, hot water soaks, elevation and oral antibiotics may obviate the need for a surgical approach.

The markedly painful abscess will fill up the space within the finger tip and will require incision and drainage. Tissue death will result if not treated promptly. Osteomyelitis or bone infection, a significant complication of felons, can take weeks to months of antibiotic therapy to eradicate.

The herpes simplex virus can cause infections of the finger called herpetic whitlow. If it infects the fingertip, it may be mistaken for a felon. The affected finger will suddenly swell, turn red and become painful. Small tiny vesicles may initially appear on the skin, then coalesce into a larger infected area. Some people may have a fever and swollen lymph nodes in the armpit and elbow.

Prompt treatment with antiviral medications like acyclovir, valacyclovir or famciclovir may reduce the infection’s severity, but is not a cure. The disease is self-limited and resolves after 14 days. It is infectious and affected people should avoid direct contact with others. The wound should be covered to reduce spread.

Herpetic whitlow can recur in 30 to 50 per cent of cases but the initial infection is usually the most severe.

Puncture wounds to the palm of the hand and fingers can introduce bacteria into the sheath of tissue that surrounds and coats the tendons. These tendons are responsible for finger flexion. Pyogenic flexor tenosynovitis is a surgical emergency. It usually requires surgical intervention and intravenous antibiotics within 12 to 24 hours after the initial infection.

Fist-fights cause injuries to the back of the hand. Commonly lacerations or punctures occur from someone’s tooth. The wounds usually lie over the knuckle. These clenched-fist injuries can quickly cause considerable damage and infection to the tendon that extends the fingers, the joint and bone. These wounds are considered to be contaminated requiring prompt surgical intervention.

The wound has to be surgically explored, irrigated and cleaned and treated with antibiotics.

It is easy to be fooled by penetrating trauma. The hand has small spaces or compartments that, if infected, can rapidly develop into serious complicated trauma leading to a permanent loss of function. Prompt evaluation by a physician is crucial. Do not delay even if the injury does not look serious. It usually is.

© Dr. Barry Dworkin 2004

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