Other problems with hand infections

Hand infections, particularly if they are not well treated can cause many problems. Here are some of them. For infections in leprosy hands, see Section 30.4.

OTHER PROBLEMS If, a few hours after a minor scratch, a patient's hand becomes hot and shiny, red lines spread up his arm, and he has rigors, a fast pulse, and severe headaches, he has lymphangitis progressing to streptococcal SEPTICAEMIA. This was common and usually fatal before the antibiotic era. Never incise such an infection, even with antibiotic cover. Give him an antibiotic first (2.9), and if an abscess or gangrene forms later, incise or deslough his hand.

If his hand has been infected as the result of a HUMAN OR ANIMAL BITE, do an efficient wound toilet under a tourniquet, excise all tissue of doubtful viability, and leave the wound open. Give him chloramphenicol and metronidazole (2.9). He is in great danger of a serious infection, particularly with anaerobes. If you treat him early, he will probably recover and have a useful, mobile hand. If he presents late with a finger like that in Fig. 8-9 it will remain stiff, especially if a joint or a tendon sheath are involved. When his infection is controlled, and if he will allow you, amputate his stiff useless finger.

If SWELLING AND TENDERNESS SPREAD ABOVE HIS WRIST, pus has probably tracked proximally behind his flexor tendons up his arm into the space of Parona, as the result of a neglected palmar infection[md]see Section 8.9. Drain it through incision 6 in Figs. 8-4 and 8-6.

If he has EXPOSED JOINTS OR TENDONS after a hand infection, leave them open for about a week until infection is controlled. Raise his hand in a roller towel (75-1), and start movements as soon as pain permits. When healthy granulations have appeared, refer him to an expert who will cover his exposed tendons with a flap. If you cannot refer him, close his wound by secondary closure without tension (seldom possible, 54.6), or by secondary split skin grafting unless you have experience in the use of flaps. This will be less satisfactory, because his fingers will not be so mobile.

If OSTEOMYELITIS develops, continue antibiotic treatment, immobilize his hand in the position of function, X- ray it 2 weeks later and remove sequestra through dorsal incisions as necessary. Osteomyelitis of the distal phalanx is common in untreated pulp infections (8.5), and can follow other hand infections. You may eventually have to amputate his infected finger[md]see below.

If it involves a metacarpal (uncommon), treat this as if it were any other long bone. Approach it through a dorsal incision, and reflect his extensor tendons. Approach his middle and lateral phalanges through midlateral incisions.

If it involves a distal phalanx this will usually present at his finger tip. Bite it off with a bone nibbler.

If DISCHARGE AND PAIN PERSIST, they are probably the result of: (1) Inadequate drainage and desloughing. (2) Osteomyelitis. (3) The spread of a more superficial infection to a tendon sheath, or another fascial space which you did not recognize initially. (4) Sloughing of a tendon. (5) A foreign body.

If an adult's FINGER CONTINUES TO BE PAINFUL AND DISCHARGE because of osteomyelitis or estabished septic arthritis of an MP or PIP joint, consider AMPUTATION, because the nearby joints may become stiff too. A stiff DIP joint is not a disability. When you amputate, do so at least through the joint proximal to the involved bone. Don't merely remove part of the involved bone, because the infection will spread. The thumb is an exception; spare as much bone as you can, and don't amputate if you can avoid doing so, because even a stiff stump of a thumb is better than no thumb. See Section 75.24.

CAUTION ! A child is much more likely to regain some useful movement eventually, so don't amputate unless his finger remains stiff after the infection has settled.

Fig. 8-9 DISASTER WITH A HUMAN FINGER BITE. The wound entered the patient's terminal IP joint which became infected. His finger might have been saved by an efficient wound toilet soon after the injury. Excise all tissue of doubtful viability, leave the wound open, and give him chloramphenicol and metronidazole. After Charles Bowesman ''Surgery and Clinical Pathology in the Tropics'. E and S Livingstone. Permission requested.