The general method for an infected hand

A badly infected hand can be a real disaster. Some infections arise spontaneously, others follow quite minor injuries, or even a seemingly trivial scratch. They are particularly common in leprosy patients (30.4, 30.6). The best prevention is an early and thorough toilet of all hand wounds. If you do this early, it is quite a minor procedure. The great danger of late or inadequate treatment is a stiff finger (75.2), which is a great disability, and may need amputation.

If you treat a patient early enough, antibiotics may be effective, and may prevent a serious lesion spreading. Some hand surgeons make little use of them, and they are certainly much less important than a careful wound toilet and early drainage.

There are many spaces in the hand where pus can collect, each with its own signs and incisions. These spaces are not rigidly defined; some run into one another, and more than one may be infected at the same time, as in Fig. 8-5, so don't be dismayed by the apparent complexity of pus in the hand. The common places for it to collect are in the pulp spaces of the fingers (8.5), and in the web spaces (8.7). Even after pus has formed, he should recover completely[md]if you treat him correctly, and provided that his tendon sheaths have not been involved.

PUS IN THE HAND IS COMMON AND SERIOUS! DON'T BE BOTHERED BY THE NUMBER OF INCISIONS! One difficulty is knowing when to incise an infected hand. Pus is so tightly trapped in the spaces of the hand that you cannot use fluctuation as a sign that it is present. A good rule to remember is that, if his hand prevented him sleeping the previous night, it needs incising.

When you operate: (1) Don't cut his digital nerves[md]remember that they run on the radial and ulnar aspects of his fingers just anterior to the tips of his finger creases, as in D, Fig. 8-6. (2) Don't cut through a more superficial abscess into his flexor sheaths underneath, or you may infect them. These are in the greatest danger where they are nearest to the surface, under the flexor creases of his fingers. So don't incise the palmar surface of a finger proximal to its distal flexion crease, unless you are deliberately draining an infected tendon sheath. (3) When you drain pus, be sure to remove the granulation tissue that surrounds it, so that the wall of the abscess is clean, and antibiotic containing blood can enter it. (4) Use a bloodless field whenever you can, so that you can see the anatomy clearly.

DON'T WAIT FOR FLUCTUATION IF PAIN KEPT HIM AWAKE LAST NIGHT, INCISE HIS HAND USE A TOURNIQUET Fig. 8-1 THE MANY PLACES WHERE PUS CAN COLLECT IN THE HAND. There are also three which are not shown here: these are the web spaces in Fig. 8-5. After ''Farquharson's Textbook of Operative Surgery', edited by Rintoul RF, Fig. 3O2 (Churchill Livingstone): and ''Campbell's Operative Orthopaedics', edited by Edmondsen AS and Crenshaw AH[md]the Chapter on ''Hand Infections' by Lee Milford, Fig. 3-357, (CV Mosby Company). Both with kind permission.

THE GENERAL METHOD [s8]FOR HAND (AND FOOT) INFECTIONS If the patient has leprosy, see Sections 30.4 and 30.6.

WHERE IS THE PUS? Feel carefully for the point of greatest tenderness by probing with a matchstick.

If his terminal phalanx is infected, consult Figure 8-2.

If his whole hand is swollen like an inflated rubber glove, the pus is probably in his mid palmar space, or in a flexor tendon sheath, especially if he cannot move his little and ring fingers.

If the greatest swelling is over the web of his thumb, he probably has pus in his thenar space, especially if his index finger is held flexed, and he cannot move it or his thumb.

If: (1) his whole finger is swollen and tender, (2) there is no obvious sign of the pus pointing, and (3) any movement of the finger is exquisitely painful, he probably has a tendon sheath infection.

If all his fingers, especially the fifth, are held semi- flexed and rigid, suspect that the tendon sheaths in his ulnar bursa are infected.

If he has lymphangitis, lymphadenitis, and fever, his infection is spreading. If pus is present, incise his hand under antibiotic cover, and continue after his temperature and pulse have become normal.

CAUTION ! Pus is much more likely to be present on the palmar surface than on the dorsum, so don't be misled by swelling on the back of his hand. The commonest cause of a swollen dorsum is a web space infection.

SPECIAL TESTS. Test his urine for sugar[md]diabetes may present as a septic infection.

TREATMENT [s7]FOR HAND INFECTIONS RAISE HIS HAND to make him more comfortable and promote healing. In less severe infections, raise his arm in the St. John's sling. In more severe ones, such as a tendon sheath infection, put him to bed and raise his hand in a roller towel: both are shown in Fig. 75-1.

ANTIBIOTICS are usually unnecessary, but if his infection is spreading (see above) give him penicillin in the dose for a severe infection. If antibiotic resistance is likely, for example if he is working in a hospital, or your local strains are apt not to respond to penicillin, give him chloramphenicol, erythromycin, or, if you can afford it, cloxacillin.

Don't forget to give him an analgesic.

INCISING [s7]HAND INFECTIONS SHOULD YOU INCISE IT? Don't try to treat an infected hand by aspiration only. Base your decision to incise it on: (1) The presence of acute local tenderness. This shows that pus is present and where it is pointing. (2) The length of his history[md]if symptoms are becoming worse after 48 hours, his hand probably needs incising. (3) The severity of the swelling. (4) The nature of his pain. If throbbing pain kept him awake last night, incise his hand.

ANAESTHESIA must be adequate. For any but the most minor infection, avoid local infiltration close to the infection, because this will only spread it and increase the swelling.

If the infection is in the distal two thirds of his finger or thumb you can use a finger block without adrenalin (A 6.21).

For all other hand infections, use an axillary block (A 6.18), or an intravenous forearm block (A 6.19), or ketamine (A 8.2), or general anaesthesia.

A TOURNIQUET is essential in all but the most superficial infections, because a bloodless field makes the operation easier (3.9). Don't exsanguinate his arm with an Esmarch bandage, because it may spread the infection.

If the pus is in the distal segment, wrap a rubber catheter twice round the base of his finger or thumb, and clamp it with a heavy haemostat.

If the pus is anywhere else, apply a pneumatic tourniquet, or an Esmarch bandage properly applied as a tourniquet (3.9).

EQUIPMENT. Use a small scalpel, fine pointed scissors, skin hooks, fine dissecting forceps, and if necessary Volkmann's spoon.

ASSISTANT. If he has a major infection, you must have an assistant scrubbed up to hold the retractors.

INCISING, DESLOUGHING AND DRAINING. Clean his skin with antiseptic. Incise where pus points, and don't adhere too slavishly to standard incisions, which are described later. We have numbered the incisions that you will need for major hand infections from 1 to 12. Most of them are shown on Fig. 8-6.

When you extend an incision, do so in a skin crease. If necessary jump from one crease to another by making a Z-shaped incision. Remove skin that is already dead. If necessary, extend an incision to explore the whole abscess cavity, and remove deeper dead tissues.

If more than one space is infected, adapt your incision(s) accordingly. For example, if his mid-palmar space, several web spaces and his tendon sheaths are infected, you may need to make several incisions like those in Fig. 8-5.

As soon as you are through his skin, insert a haemostat, open it, and explore the abscess cavity (Hilton's method). Culture the pus.

If there are no vulnerable structures such as periosteum, nerves or tendon sheaths, nearby, scrape away the lining of his abscess with curette or a swab. If there are vulnerable structures nearby, be more cautious, and only use a swab.

Drain the abscess by putting a piece of rubber glove into it. Or, leave a piece of vaseline gauze between the wound edges.

CAUTION ! (1) Don't cut his nerves, see Fig. 8-6. (a) His digital nerves run near the anterolateral margins of his fingers. So either cut near the middle of the palmar surfaces of his fingers, or on their lateral surfaces fairly posteriorly at the apex of his finger creases. (b) The muscular branch of his median nerve comes off the main trunk just distal to the tuberosity of his scaphoid and curves round into his thenar muscles. (2) Don't pack the wound tightly.

TO CONTROL BLEEDING remove the tourniquet, raise his arm and press firmly on the wound for 5 to 10 minutes without interruption.

POSTOPERATIVELY, be sure to elevate his hand, until pain and swelling subside[md]this is an important way of reducing stiffness. Rapid resolution of inflammatory oedema is more important than early movement in reducing stiffness. Wrap the wound with plenty of gauze, and use the dressings to splint it in the position of safety (75.8). Leave them on for several days, unless the wound becomes painful, or swells, or there is much discharge. When you change the dressings, use careful aseptic precautions, so as to avoid secondary infection. If they stick, soak them off in saline, and then gently remove them.

If the infection was extensive, check 2 to 4 days later for residual infection or necrotic tissue which may need treatment.

CAUTION ! Start active movements as soon as pain has subsided.