Author:

Chester D.Shermer

Signs and Symptoms

• Paronychia:
  • Localized edema, erythema, and pain in proximal portion of lateral nail fold
  • Fluctuance may be present and may extend beneath the nail margin
  • Systemic signs and symptoms are usually not present
• Felon:
  • Erythema and tense swelling of the distal pulp space that does not extend proximal to the proximal interphalangeal (PIP) joint
  • Aching pain early, severe throbbing pain late
  • Systemic signs are usually not present
• Herpetic whitlow:
  • Distal pulp space is swollen, but remains soft
  • Lateral nail folds may be affected
  • Throbbing pain of the distal pulp space
  • Vesicles containing nonpurulent fluid are present and may form bullae
  • Systemic symptoms may be present:
    • Fever
    • Lymphadenopathy
    • Constitutional symptoms
• Flexor tenosynovitis:
  • Kanavel signs:
    • Severe pain and symmetric edema of the digit
    • Tenderness over the course of tendon sheath
    • Flexed position of the finger at rest
    • Pain on passive extension of the finger - may be the only finding in early infection
• Clenched fist injury:
  • Laceration over the metacarpophalangeal (MCP) joint from striking an object with a clenched fist
  • Any laceration over the MCP must be assumed to be a human-bite wound until proven otherwise
• Web space abscess:
  • Pain and edema of the affected web space and adjacent palm
  • Fingers are held abducted
• Palmar space infections:
  • Thenar space infection:
    • Pain, tenderness, tense edema of thenar eminence
    • Dorsal edema without tenderness
    • Thumb is held abducted and flexed, and passive adduction is painful
  • Midpalmar space infection:
    • Pain, edema, and tenderness of the midpalmar space
    • Dorsal edema without tenderness
    • Motion of middle and ring fingers is painful
  • Hypothenar space infection:
    • Pain and fullness over hypothenar eminence
    • No limitation of finger movement

Essential Workup

Most hand infections are diagnosed by history and physical exam with special attention to neurovascular status

Diagnostic Tests & Interpretation

Differential Diagnosis

• Paronychia should be differentiated from herpetic whitlow and felon
• The differential for palmar space infection includes flexor tenosynovitis, cellulitis, and web space infection

Prehospital

Hand immobilization as appropriate

ED Treatment/Procedures

• Paronychia:
  • Early paronychia/simple cellulitis without purulence present may be managed with oral antibiotics and rest:
    • Amoxicillin-clavulanate, ciprofloxacin, doxycycline, trimethoprim-sulfamethoxazole, cefuroxime, penicillin VK
    • Clindamycin or metronidazole, if associated with nail biting or oral contact
  • Superficial infections are drained by inserting a no. 11 blade between nail and eponychium, and lifting the eponychium from the nail
  • If necessary, the lateral nail fold may be incised tangential to the curvature of the nail
  • When pus is present under the adjacent nail, 1/4 of the nail should be removed
  • When pus is present under the dorsal roof of the proximal nail, remove 1/3 of the proximal nail
• Felon:
  • A lateral incision avoiding the neurovascular bundle is preferred
  • However, a small skin-only incision with no. 11 blade over the area of maximum swelling and tenderness can be utilized
  • More extensive felons are drained through a unilateral longitudinal incision that does not cross the distal interphalangeal (DIP) flexor crease
  • Disruption of fibrous septa is no longer recommended:
    • Results in an unstable fingertip
    • Loculations may need to be broken up
  • Give oral antibiotics to cover skin pathogens, place a drain, and recheck in 48 hr:
    • Cephalexin, dicloxacillin, clindamycin, trimethoprim-sulfamethoxazole, amoxicillin-clavulanate
• Herpetic whitlow:
  • Usually self-limited; do not incise and drain
  • Oral acyclovir may be given to patients with systemic involvement
• Flexor tenosynovitis, web space abscess, palmar space infection:
  • Elevation, IV antibiotics, and pain control:
    • Vancomycin, levofloxacin, ciprofloxacin, ceftriaxone
  • All of these infections require immediate consultation with a hand surgeon
• Clenched fist injury:
  • Elevation, IV antibiotics, tetanus prophylaxis, and pain control in the ED:
    • Ampicillin/sulbactam, ceftriaxone, ticarcillin/clavulanate, piperacillin-tazobactam, metronidazole
  • All bite wounds with evidence of infection or joint involvement require emergent consultation with a hand surgeon
  • If there are no signs of infection and no joint penetration, patients may be considered for outpatient treatment with oral antibiotics after appropriate irrigation and wound care:
    • Ampicillin/clavulanate or penicillin V + cephalexin or dicloxacillin or metronidazole
    • Do not primarily close lacerations associated with a human bite; delayed primary closure or healing by secondary intention is appropriate

Medication

• Acyclovir: 400 mg PO t.i.d for 10 d (peds: Not recommended for herpetic whitlow)
• Amoxicillin/clavulanate: 875/125 mg PO b.i.d (peds: 40 mg/kg/d PO div q6h)
• Ampicillin/sulbactam: 1.5-3 g IV q6h (peds: 300 mg/kg/d IV q6h)
• Cefoxitin: 2 g IV q8h (peds: 80-160 mg/kg/d IV/IM div q6h)
• Cephalexin: 500 g PO q.i.d for 7 d (peds: 40 mg/kg/d PO div q6h)
• Clindamycin: 300-450 mg PO q.i.d for 7 d. Can use IV in severe cases: 600-900 mg IV q8h (peds: 20-40 mg/kg/d div q8h PO/IV/IM)
• Dicloxacillin: 500 mg PO q.i.d for 7 d (peds: 12.5-50 mg/kg/d PO div. q6h)
• Metronidazole 500 mg PO t.i.d (peds: 7.5-30 mg/kg/d div q 12h PO/IV)
• Penicillin V: 500 mg PO q.i.d (peds: 40 mg/kg/d PO div q6h)
• Ticarcillin/clavulanate: 3.1 g IV q4-6h (peds: 150-300 mg/kg/d IV div q6-8h)
• Piperacillin/tazobactam: 3.375 g IV q6h (peds: 300 mg/kg/d IV div q8h)
• Trimethoprim-sulfamethoxazole: 10 mg/kg/d TMP PO/IV q12h

Disposition

Follow-up Recommendations

Usually arranged by admitting physician after operative therapy

• AntosiaRE, LynE. The hand . In: RosenP, BarkinR, DanzlD, et al., eds. Emergency Medicine: Concepts and Clinical Practice. 4th ed.St. Louis, MO: Mosby; 1998:625-668.
• BachHG, SteffinB, ChhadiaAM, et al. Community-associated methicillin-resistant Staphylococcus aureus hand infections in an urban setting . J Hand Surg Am. 2007;32(3):380-383.
• BarabasA, FlemingANM. Hand infections. In: TrailI, FlemingA (eds). Disorders of the Hand . London: Springer; 2015.
• MakhniMC, MakhniEC, SwartEF, et al. Hand infections. In: MakhniM, MakhniE, SwartE, et al., eds. Orthopedic Emergencies. Cham: Springer; 2017.
• OngYS, LevinLS. Hand infections . Plast Reconstr Surg. 2009;124(4):225e-233e.

See Also (Topic, Algorithm, Electronic Media Element)

Hand Infections http://emedicine.medscape.com/article/783011-overview

ICD9

• 112.3Cand idiasis of skin and nails

• 681.02 Onychia and paronychia of finger

• 914.9 Other and unspecified superficial injury of hand (s) except finger(s) alone, infected

• 054.6 Herpetic whitlow

• 681.01 Felon

• 682.4 Cellulitis and abscess of hand , except fingers and thumb

• 727.05 Other tenosynovitis of hand and wrist

ICD10

• B37.2 Cand idiasis of skin and nail

• L03.019 Cellulitis of unspecified finger

• S61.439A Puncture wound w/o foreign body of unsp hand , init encntr

• B00.89 Other herpesviral infection

• L02.511 Cutaneous abscess of right hand

• L02.512 Cutaneous abscess of left hand

• L02.519 Cutaneous abscess of unspecified hand

• L02.51 Cutaneous abscess of hand

• L03.011 Cellulitis of right finger

• L03.012 Cellulitis of left finger

• L03.01 Cellulitis of finger

• M65.149 Other infective (teno)synovitis, unspecified hand

SNOMED

• 62573007 Superficial injury of hand with infection (disorder)

• 71906005 Paronychia (disorder)

• 200744008 chronic paronychia (disorder)

• 43891009 herpetic whitlow (disorder)

• 32021005 Pulp abscess of finger (disorder)

• 3633001 Abscess of hand (disorder)

• 423778009 tenosynovitis of hand (disorder)

• 62837005 Cellulitis of hand