How best to approach these acute hand infections

,

Applied Evidence

How best to approach these acute hand infections

J Fam Pract. 2020 January;69(1):E1-E8

PDF Download

References

1. Lewis MA. Herpes simplex virus: an occupational hazard in dentistry. Int Dent J. 2004;54:103-111.

2. CDC. Recommended infection-control practices for dentistry. MMWR Morb Mortal Wkly Rep. 1993;42:1-16.

3. Merchant VA, Molinari JA, Sabes WR. Herpetic whitlow: report of a case with multiple recurrences. Oral Surg. 1983;555:568-571.

4. Richards DM, Carmine AA, Brogden RN, et al. Acyclovir. A review of its pharmacodynamic properties and therapeutic efficacy. Drugs. 1983;26:378-438.

5. Laskin OL. Acyclovir and suppression of frequently recurring herpetic whitlow. Ann Int Med. 1985;102:494-495.

6. Schwandt NW, Mjos DP, Lubow RM. Acyclovir and the treatment of herpetic whitlow. Oral Surg Oral Med Oral Pathol. 1987;64:255-258.

7. Robertson J, Shilkofsk N, eds. The Harriet Lane Handbook. 17th Edition. Maryland Heights, MO; Elsevier Mosby; 2005:679-1009.

8. Usatine PR, Tinitigan R. Nongenital herpes simplex virus. Am Fam Physician. 2010;82:1075-1082.

9. Newfield RS, Vargas I, Huma Z. Eikenella corrodens infections. Case report in two adolescent females with IDDM. Diabetes Care. 1996;19:1011-1013.

10. Patel DB, Emmanuel NB, Stevanovic MV, et al. Hand infections: anatomy, types and spread of infection, imaging findings, and treatment options. Radiographics. 2014; 34:1968-1986.

11. Blumberg G, Long B, Koyfman A. Clinical mimics: an emergency medicine-focused review of cellulitis mimics. J Emerg Med. 2017;53:474-484.

12. Kilgore ES Jr, Brown LG, Newmeyer WL, et al. Treatment of felons. Am J Surgery. 1975;130:194-198.

13. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:e10-e52.

14. Baron EJ, Miller M, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis. 2013;57:e22–e121.

15. Clark DC. Common acute hand infections. Am Fam Physician. 2003;68:2167-2176.

16. Swope BM. Panonychiae and felons. Op Tech Gen Surgery. 2002;4:270-273.

17. Yen C, Murray E, Zipprich J, et al. Missed opportunities for tetanus postexposure prophylaxis — California, January 2008-March 2014. MMWR Morb Mortal Wkly Rep. 2015;64:243-246.

18. Barry RL, Adams NS, Martin MD. Pyogenic (suppurative) flexor tenosynovitis: assessment and management. Eplasty. 2016;16:ic7.

19. The symptoms, signs, and diagnosis of tenosynovitis and major facial space abscess. In: Kanavel AB, ed. Infections of the Hand. Philadelphia, PA: Lea & Febiger; 1912:201-226.

20. Kennedy CD, Huang JI, Hanel DP. In brief: Kanavel’s signs and pyogenic flexor tenosynovitis. Clin Ortho Relat Res. 2016;474;280-284.

21. Krieger LE, Schnall SB, Holtom PD, et al. Acute gonococcal flexor tenosynovitis. Orthopedics. 1997;20:649-650.

22. Giladi AM, Malay S, Chung KC. A systematic review of the management of acute pyogenic flexor tenosynovitis. J Hand Surg Eur Vol. 2015;40:720-728.

23. Gutowski KA, Ochoa O, Adams WP Jr. Closed-catheter irrigation is as effective as open drainage for treatment of pyogenic flexor tenosynovitis. Ann Plastic Surgery. 2002;49:350-354.

24. Kennedy SA, Stoll LE, Lauder AS. Human and other mammalian bite injuries of the hand: evaluation and management. J Am Acad Orthop Surg. 2015;23:47-57.

25. Henry FP, Purcell EM, Eadie PA. The human bite injury: a clinical audit and discussion regarding the management of this alcohol fueled phenomenon. Emer Med J. 2007;24:455-458.

26. Zubowicz VN, Gravier M. Management of early human bites of the hand: a prospective randomized study. Plas Reconstr Surg. 1991;88:111-114.

27. Kelly IP, Cunney RJ, Smyth EG, et al. The management of human bite injuries of the hand. Injury. 1996;27:481-484.

28. Udaka T, Hiraki N, Shiomori T, et al. Eikenella corrodens in head and neck infections. J Infect. 2007;54:343-348.

29. Decker MD. Eikenella corrodens. Infect Control. 1986;7:36-41.

30. Griego RD, Rosen T, Orengo IF, et al. Dog, cats, and human bites: a review. J Am Acad Dermatol. 1995;33:1019-1029.

31. Panlilio AL, Cardo DM, Grohskopf LA, et al. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54:1:17.

32. American Academy of Pediatrics. Hepatitis B. In: Kimberlin DW, Brady MT, Jackson MA, Long SS. Eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL. American Academy of Pediatrics; 2018:415.

33. Chapman LE, Sullivent EE, Grohskopf LA, et al. Recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings and other mass-casualty events—United States, 2008: recommendations of the Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 2008;57:1-21.

34. Harrison M. A 4-year review of human bite injuries presenting to emergency medicine and proposed evidence-based guidelines. Injury. 2009;40:826-830.

35. Taplitz RA. Managing bite wounds. Currently recommended antibiotics for treatment and prophylaxis. Postgrad Med. 2004;116:49-52.

36. Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis. 2007;44:705-710.

37. Shapiro DB. Postoperative infection in hand surgery. Cause, prevention, and treatment. Hands Clinic. 1998;14:669-681.

What you’ll see. FTS is diagnosed using clinical criteria^19,20: fusiform swelling of the finger; exquisite tenderness over the entire course of the flexor tendon sheath; pain on passive extension; and flexed posture of the digit (FIGURE 3). Patients usually recall some type of trauma or puncture wound to the affected area, but hematogenous spread of Neisseria gonorrhoeae also has been reported.²¹ The most common bacterial pathogens are Staphylococcus sp or Streptococcus sp. However, obtain a sample for Gram stain and culture for aerobic, anaerobic, AFB, and fungal agents before irrigating the wound with copious fluids and initiating empirical antibiotic therapy.¹⁴ Once a pathogen has been isolated, tailor antimicrobial therapy based on identified sensitivities and local antibiogram.¹³

How it’s treated. Early treatment of FTS is of utmost importance to avoid adverse outcomes. If FTS is diagnosed early, manage conservatively with elevation of the hand, splinting in a neutral position, and intravenous (IV) antibiotics. The use of adjunct antibiotics has improved range-of-motion outcomes compared with elevation and splinting alone (54% excellent vs 14% excellent) (SOR: A).²²In the most complex or fulminant cases, when conservative treatment has failed to show improvement (FIGURE 4), surgical management is indicated.²²

Surgical management of FTS has involved either an open or closed method. The open approach consists of open incision and drainage with exposure of the flexor tendon sheath, followed by large-volume sheath irrigation and closure of incision, in some cases over a drain. The closed approach with irrigation, rather than open washout, has been associated with improved outcomes (71% excellent vs 26% excellent).²² As a result, the procedure of choice is the closed approach, which uses closed catheter irrigation. An incision and placement of an angiocatheter allows for gentle irrigation of the wound until all purulent material has been evacuated (SOR: C).^22,23

Human bite injuries

A human bite injury occurs in 1 of 2 ways, and each has a distinct pattern.

What you’ll see

Closed-fist injury occurs when a clenched fist strikes the teeth of another person. The resulting lesion can easily fool a clinician by appearing to show very little damage. If not appropriately evaluated and treated, the lesion can cause considerable morbidity (FIGURE 5). Injury to the extensor mechanism and joint capsule can also damage the articular cartilage and bone, allowing bacteria to grow in a closed environment. This usually affects the metacarpophalangeal joint (MCP) due to its prominence when a hand is clenched. Initially the lesion seems to be minor, with a small laceration of 3 to 5 mm on the overlying skin, thus inoculating mouth flora deep in the hand tissue. Once the hand is relaxed, the broken skin retracts proximally, covering the wound and making it look innocuous.²⁴

Continue to: Occlusive bite injury...