POSTGRAD. MED. J. (1964), 40, 247

PREVENTION AND TREATMENT OFHAND INFECTIONS

T. G. LOWDEN, M.A., F.R.C.S.Surgeon, Royal Infirmary, Sunderland

MOST hand infections cannot be traced to aprecise source, though it is likely that in all ofthem a minor, unnoticed breach of skin surface hasallowed entry of pyogenic organisms. Prophylaxisis therefore difficult, but attention to pricks, smallcuts or abrasions as soon as they are sustained,simple cleansing or the early application of aprotective dressing will help to reduce them.Industrial and household gloves and barrier creamsare also useful. The chance of a minor injurygiving rise to a hand infection is increased in thosewhose skin habitually harbours pathogens.Williams and Miles (I949) showed that handinfections after minor injury occur more often incarriers of staphylococcus aureus, and the infectingorganism often corresponds with organismsisolated from the neighbouring skin. A corres-pondence between infecting strain and a straincarried in the nose has also been noted. Thisshould be considered in patients who say that theirminor wounds often go septic. Where it is pos-sible, reservoirs of infection should be eliminated.

BacteriologyIn a small number of cases streptococcus pyogenes is

probably primarily responsible. In some staphylococcusaureus is associated with streptococcus pyogenes, and inthese the staphylococcus usually determines the clinicalcharacter of the infection. The majority are due tostaphylococcus aureus. Coliforms are occasionallyisolated in pure culture, especially from finger-tiplesions. Coliforms, pseudomonas pyocyaneus, strepto-coccus pyogenes, and strains of staphylococcus aureusother than the causative strain may appear in lesionswith persistent discharge and a protracted course. Inclinics and hospitals the tendency for samples ofstaphylococcus aureus to show antibiotic resistanceincreases with the time taken for the lesions to heal.Most cases of septic hand are contracted in industryor in the home and the strains encountered there arepredominantly penicillin sensitive. But if it is suspectedthat infection has started in hospital, amongst hospitalor medical staff, or in a family with recent hospitalcontacts, this may not be so.

Specific InfectionsDifferentiation between pyogenic and specific

infections is usually easy on clinical grounds,provided the latter are kept in mind. In somecases bacteriological confirmation may be difficult.Tuberculosis produces a variety of lesions in thehand-dactylitis, soft tissue abscess, and chroniculceration at the surface (Fig. i) being the more

FIG. I.-Tuberculous ulcerof finger-tip.

FIG. 2.-Orf.

common. Breakdown in axillary glands occursmore often in the two latter than in bony disease.Orf (Fig. 2) is a virus infection giving rise to ashallow ulcer with a natural limit of about sixweeks. Isolation of the virus is difficult but thelesion is commonly secondarily invaded by pyo-genic organisms. Erysipeloid is an intradermal in-flammation of slow progress, again self-limiting.Confirmation is not possible because there is nodischarge and no material available. Biopsy is notjustified, because it recovers spontaneously.Diphtheritic infection is secondary to long-standingdischarging lesions. It is rare in this country, but

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248 POSTGRADUATE MEDICAL JOURNAL May I964

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FIG. 3.-Plaster of Paris splint for conservative treatment of septic hands.

very important when it does occur because it canresult in neuritis or cardiac complications.

Conservative TreatmentThe management of early cases calls for

repeated attendances and daily assessment. It isat this stage that the right decision makes thedifference between a short disability with nooperation and a long disability, one or moreoperations, and perhaps permanent disablementat the end of it. Even a small degree of contracture,or a small area of impaired sensation, which couldhave been avoided, is too high a price to pay inthe hand-and residual limitations after septichands, even now, are not always small.

In hospital clinics about 8o% of septic handcases attend for the first time with signs of pus.Half the remainder show these signs within a dayor two of attendance, and only the remaining io%resolve without them. In the community as awhole such figures are quite inapplicable. It isdifficult to estimate how often minor hand infectionsresolve with conservative treatment, or indeedwith no treatment at all, because most of them donot attend clinics where records are kept. Iftreatment is prompt, response should be expectedin the majority.The mainstay of early treatment is rest to the

whole hand, and maintenance of adequate bloodlevels of penicillin. Rest is provided by a com-fortable splint to the hand and forearm (Fig. 3),and a large arm sling. The patient is told to put abolster alongside himself at night to prevent thearm falling outwards and becoming cramped.Penicillin is usually effective, and daily injectionsof long-acting preparations are adequate.The first sign of response is an improvement in

comfort, and if it is prompt, treatment is continued.Failure to respond to these two measures within48 hours of beginning treatment is, I believe,presumptive evidence of the presence of pus. Itis not presumptive evidence of infection by anti-

biotic-resistant organisms, except possibly in thefew types of hospital infection already mentioned.It is wrong to wait for 'fluctuation' at the site ofinfection. It is an unreliable sign in hands, and ifit is due to pus it often means extensive involve-ment of skin and is followed by an ulcer withdelayed healing. Decisions should have been madeearlier than this.The appearance of pus under the cuticle, or an

area under the swelling where tenderness is moremarked than elsewhere, or a discharge, are clearindications to consider surgery.A few cases need admission to hospital, usually

on general grounds rather than because of theseverity of the infection itself. Sometimesoperations last longer than would be advisable onan out-patient, and medical conditions (such asdiabetes, conditions needing steroid therapy,hypertension, and extreme old age) may indicate aperiod of stabilization before operation, or specialcare afterwards.

Surgical TreatmentThe use of antibiotics before operation is

acknowledged to be one of the main factors inimprovement of end-results, as well as one of themain reasons why many cases resolve withoutsurgery. It is not established that routine anti-biotics after operations are of benefit, and there issome evidence that they are not (Anderson, I958).Choice of antibiotics may vary according to localconditions, but many clinics report, as late as I962(Parsons, I962), that penicillin is still in general use.

It is not possible to indicate here all the surgicaldetails of approach to abscess cavities in the hand,but a tendency is detected to abandon the routine'classical' incisions as recommended by Kanavel(I939) in 1928. A direct approach through morelimited incisions is more often used. Explorationof the cavity and cleaning of its ramifications arefollowed by closure of the residual space bybandaging. This results in fewer post-operative

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MIay 1964 LOWDEN: Prevention and Treatment of Hand Infections 249

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FIG. 4.-Nail removal in treatment of paronychia. (a) and (b) Subcutaneous abscess in sulcus;no nail is removed. (c) Sulcus abscess extending under part of the nailbase; all the nailbase isremoved. (d) Extension under all the nailbase; all the nailbase is removed. (e) Distal abscessof nailbed and subcutaneous tissue at the tip; enough nail is removed to expose the involvednailbed fully. (f) Extension under part of nailbase and part of distal nailbed; the whole ofnailbase is removed; enough nail is removed distally to expose the involved nailbed fully.(g) Spread under the whole of the nail; all the nail is removed.

dressings, and a better prospect of healing withoutsecondary infection. Drainage by foreign materialand counter-incisions are also less frequentlyneeded. Relapse after operation is usually due to afailure to detect the full extent of the lesion, butoccasionally to later extension of tissue necrosis ordevelopment of osteitis (these two usually in thepulp space) or to an unsuspected foreign body(usually in palm or thenar or hypothenar em-inences).

Small incisions are sited where the cavity mostnearly approaches the surface, where there is asmall sinus, or an area of increased redness andsoftness of the skin, or a point of maximumtenderness on blunt pressure by the end of aprobe. The direction of the incision is determinedby the natural creases rather than by the suspectedshape of the abscess cavity. An area of skin necrosisalready established is often quite adequate for fullexploration, without any incision. All cases areoperated on under a tourniquet.The spread of infection under the epidermis is

seldom of importance if the blister is trimmed backexactly to its limits and the pus is dried away.

But it sometimes masks the extent of the lesionunderneath so that a full assessment of the situa-tion is not made until after the operation hasstarted. It expects of the surgeon a willingness toalter his decisions or even to come to them for thefirst time while the operation is going on, and therealization that the best results come from suitingthe piocedure to the particular situation. Eachcase must be treated on its own merits.

After operation some hands profit by furtherrest and elevation, but most are comfortablewithin twenty-four hours. Early function isencouraged. The wound area is kept dry andporous bandages are bettel than occlusive dressings.The patient is told to keep his whole dressing dry.If he does this it does not need to be changed moreoften than twice a week.

ParonychiaThis versatile approach to the surgery of the

septic hand is illustrated by infections near thenailbed. They may be in the subcutaneous tissueat the base or sulcus, or subcuticularly in the skinof the same region or under the nail in the nailbed

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FIG. 5.'The usual situation of deep palmar abscess.

itself. They may be both. The extent of spreadin these situations determines the mode ofexposure,and the amount of nail, if any, which should beremoved. Removing too much nail can leave a rawnailbed, secondarily infected, whose recovery maytake considerably longer than the rest of the lesion.Removing too little may cause relapse. Between aquarter and a third of the nail is covered by nail-fold, and if pus spreads under this part it has extradifficulty in draining. The whole of the nailbaseshould be removed (Bailey, I963) so that the foldfalls back firmly over its whole extent, and thespace under it should be cleaned of debris andmacerated cuticle before it is allowed to do so.Extent of spread under the distal part varies fromcase to case and the amount of nail removal variescorrespondingly (Fig. 4).Pulp SpaceA direct approach to abscesses in the pulp space

and removal of all infected material at the primaryoperation, have reduced the relapse and compli-cation rate. Late, neglected cases are sometimesfollowed by sequestration of the distal two-thirdsof the phalanx; by destruction of the flexorinsertion; by invasion of the distal interphalangealjoint-or, most commonly, by development of athin rigid shell of skin and fibro-fatty tissue, heldopen by the phalanx in its depths, and creating anuncollapsible cavity, persistently discharging andreinfecting itself. Necrosis of skin and fibro-fattytissue is responsible for more disability and delayin healing than is any other complication. Delayin recourse to surgery is its cause.

Volar Crease and Volar CompartmentSome cases, especially in the volar creases, are

complicated by local extension into the flexorsheath. It tends to wall itself off without extendinginto the other parts of the sheath. Generalizedswelling of the finger and resistance to passiveextension of all joints are therefore unusual.

Limitation of movement at the nearest joint,however, is common. Skin and fibro-fattydestruction, combined with localized adhesion oftendon to sheath and scar, may result in permanentcontracture at this joint, and although the clinicalcourse of these infections is less dramatic than in ageneralized tendon sheath infection, importantlimitation of movement may be a permanent after-effect.Removal of sloughing skin and fibrous tissue

should be done very carefully in these cases, forfear of damaging the sheath before it is knownwhether it is involved or not. Local involvementof the sheath will drain satisfactorily through thelocal lesion. (See also tendon sheath infection.)Deep Palmar Infection. SubaponeuroticThenar and Hypothenar Eminences

Infection and abscess formation extending deepto the aponeurosis, spreading amongst (but rarelyinto) the tendon sheaths and neurovascular bundles,may be encountered (Fig 5). The subcutaneouscavity is explored, and the exploration is thenextended downwards by separating the apo-neurosis in the direction of its fibres, and excisinga portion of it if there is necrosis of its tissue. Itmay be necessary to increase exposure by incision,but such extensions can often be sutured at theend of the operation. Although these abscessescause swelling on the dorsum, there is seldom anyindication to provide deeper drainage than thatdescribed. Mid-palmar space and thenar spaceinfections, as defined by Kanavel (1939) are veryrare occurrences in this country at the presenttime. They arose from rupture of long-neglectedtendon sheath infections, and under modernconditions tendon sheath infections do not progressuntreated to such extremes.

Median Nerve InvolvementSubaponeurotic infections may extend distally

under the transverse carpal ligament, and this

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May i964 LOWDEN: Prevention and Treatment of Hand Infections 251

imperils the median nerve. Pressure on it leads toparaesthesia, and perhaps to paresis, if the compli-cation is not borne in mind. Decompression ofthe carpal tunnel (Bailey, I963) reverses theprocess, provided intervention is not delayed.Antibiotic therapy is continued for longer thanusual. Suitable support by plaster of Paris splintand careful bandaging prevent prolapse of theflexor tendons. Physiotherapy is often needed.

Tendon SheathRapid spread through the whole of the flexor

sheath, usually after a small penetrating woundon the volar surface, produces a painful, swollenfinger, with maximum tenderness at the proximalend of the sheath-or, in the case of the ulnarbursa, at the level of the middle of the fifthmetacarpal bone. These infections are usuallystreptococcal, and early treatment with penicillin,and local rest, is followed by complete resolutionin the majority. Failure to resolve promptly or,perhaps, resolution of pain but persistence of theswelling and limitation of movement (especiallylimitation of passive extension) indicate the needfor surgical intervention. The proximal end ofthe sheath is exposed by a limited incision in theskin and the sheath decompressed by a smallincision into it. The sheath is irrigated withpenicillin (io,ooo u. per ml.) through a uretericcatheter before closure of the skin wound. Furtherantibiotic therapy, together with splintage, untilresolution is complete, are then indicated. Physio-therapy is occasionally needed to encourage fullreturn to function. The majority of results inthis condition are now good, provided the casepresents for treatment wi-hin the first forty-eighthours. The severe pain of the early stages usuallyensures that it does.

Local infection of the sheath from establishedstaphylococcal infection in the volar subcutaneousspaces (q.v.) is treated quite differently. Never-theless, some cases are seen in which localsuppuration, well contained, is associated with asympathetic effusion into the more proximal partof the sheath. These cases produce a confusingclinical picture. The safest approach to them isfirstly to treat the local (and usually distal) tendoninvolvement by cleaning out the subcutaneousinfection. This allows any sheath abscess to drainthrough this area. The effusion into the proximalsection of the sheath is then approached at itsproximal end by a separate operation. It isdecompressed, as described above, without break-ing through to the distal abscess. If the barrierbetween the two parts of the sheath is brokendown, it may result in rapid extension of suppura-tion proximally and ultimate loss of function of thewhole tendon.

...w

FIG. 6.-Acute suppurative arthritis in a chronicarthritic joint.

Suppurative ArthritisSuppuration in interphalangeal joints occurs

after penetrating wounds, or by spread fromadjacent subcutaneous infections or-rarely-after infection of the tendon sheath. It takes along time to heal. Chronic arthritic joints in theelderly are very susceptible (Figs. 6 and 7).Exploration of the joint (from the side, or througha damaged extensor tendon) may reduce thehealing time if all infected material, sequestra, ornecrotic cartilage are removed by gentle curettage.It may be possible to suture the wound at the endof the operation (Bailey, I963). Often all that canbe hoped for, especially in the elderly, is anankylosis in good position, and an early decisionto amputate may be correct-particularly wherethe proximal interphalangeal joint or meta-carpophalangeal joint is involved in the youngersubject. Where suppurative arthritis is associatedwith extensive soft tissue necrosis, and sometimestendon necrosis also, early amputation becomeseven more appropriate (Fig. 8).

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252 POSTGRADUATE MEDICAL JOURNAL May 1964

9'.d.

':'·::· ':i:'::i::· .:'r.':::::::i:..·:.'.·.i.

?i ·1...--·:·.::.·I··;·: :::·-::::.·'·.·:·:9

:::::·::.I,,!:::::il:.·:B..:i·i:i.·. 5il·.:''i:r9.iw .':::::' ::'': .ii'i

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FIc. 7.--X-ray appearance of case shown in Fig. 6.

Secondary OperationsSurgical treatment is not always complete when

the infection is overcome. Permanent disability isthe result of scarring, and early attempts tominimize scar formation are an important part ofthe management of septic hands. Skin replace-ment, as soon as the infected area will accept it,is the most effective procedure. Whereverspontaneous closure cannot be anticipated withina few days, grafting should be considered. Delayin decision commits the surgeon to an operation onreinfected granulations with a thickened fibrousbase, in which the tendency to contract is alreadyestablished. It is not possible to elaborate thissubject here, because different cases pose differentproblems, to be countered by different details.

....

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i-i

FIG. 8.--Suppurative arthritis, osteitis of phalanx, andsuppurative tenosynovitis in one finger--a case foramputation.

But it is important to emphasize that the moderntreatment of septic hands involves not onlyconsideration of the infecting agent and of over-coming it, but of vigorous and early attempts torepair the damage as completely as possible.

Figs. I, 2, 3, 5, 6, 7 and 8 are reproduced from 'TheCasualty Department' by kind permission of E. & S.Livingstone & Co., Edinburgh and London.

REFERENCESANDERSON, J. (1958): Dispensibility of Post-operative Penicillin in Septic Hand Surgery, Brit. med. J., ii, 1569.BAILEY, DAVID A. (1963): 'The Infected Hand'. London: H. K. Lewis.KANAVEL, A. B. (1939): 'Infections in the Hand'. Philadelphia: Lea and Febiger.PARSONS, D. W. (I962): Treatment of the Septic Hand, Proc. roy. Soc. Med., 55, 445.WILLIAMS, R. E. 0., and MILES, A. A. (I949): Infection and Sepsis in Industrial Wounds of the Hand. Spec. Rep. Ser.

med. Res. Coun. (Lond.), No. 266.

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