Upper Extremity > Hand Infections > Flashcards

Hand Infections Flashcards

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1
Q

How do you classify hand infections

A
  • Acute vs chronic
  • By anatomic site
    • skin, subcut, deep space, tendon, muscle,
  • By organism
    • bac, viral, fungal, parasitic, protozoal
  • By etiology
    • trauma, human/animal bute, IVDU, immunocompromise, post-op
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2
Q

What special tests are used for identification of fungal, mycobacteria and HSV infections?

A
  • Fungal: KOH, Giemsa, Silver stains
    • Hyphae, spores, mycelia
  • Mycobacteria/Nocardia: Ziehl-Niessen stain
  • HSV: Tzank smear
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3
Q

What are treatment principles of hand infection

A
  • Debridement
  • I&D
  • Splint, Elevation, Rest
  • Antibiotics
  • Early rehab
  • For surgical Tx
    • dont exsanguinated for tourniquet
    • local takes longer to work
    • plan for extension of incisions not over NV bundles
    • plan for multiple washouts
    • cultures from intraop samples
    • Joints - avoid aspiration over area of cellullits
    • Send joint fluid for cell count, C&S, Glc, protein
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4
Q

What are approaches to joints for washout of infection

A
  • Radio carpal jt - b/w 3/4 compartments
  • MCP jt - dorsal and split extensor
  • PIP jt - midaxial, split TRL, protect central slip
  • DIP jt - H or Y incision, protect TT
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5
Q

What are mimickers of infection to keep on DDX

A
  • Gout/Pseudogout
    • sent jt aspirate for crystals, Rheum referral
  • Acute calcific tendonitis
    • NSAIDs, Rheum referral
  • FB
  • Pyogenic granulosum
    • excise and cauterize base
  • Pyoderma gangrenosum
    • macult->papule w raise violaceous borders, associated w UC.
    • Do not excise - treat w steroids and wound care
  • Spider bite
    • brown recluse spider leads to ST necrosis
  • Metastatc or 1’ tumor
    • SCC BCC melnaoma KA
    • DP primary site for bone mets (source thyroid, prostate, breast, lung, kidney, colon
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6
Q

What are the 3 potential spaces for infections in the hand and forearm

A
  • Hand
    • thenar
    • hypothenar
    • midpalm
  • Forearm
    • Paronas space
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7
Q

What are the 9 spaces (includes 4deep and 5 superficials)

A

DEEP

  • thenar
  • hypothenar
  • midpalm
  • Paronas

Superficial

  • dorsal subcutaneous
  • dorsal subaponeurotic
  • interdigital webspace
  • radial bursa
  • ulnar bursa
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8
Q

Define boundaries of thenar space deep infection, symptoms/signs and treatment

A

THENAR SPACE

  • Roof: D2 flexor sheath and palmar fascia
  • Floor: Adductor fascia
  • ulnar border: D3 MC vertical septum to palmar fascia
  • radial border: confluence of AddP fascia and muscle at insertion to PP

Findings: thumb abducted, pain w opp/abd

Tx:

I&D across thenar crease and dorsal webspace

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9
Q

Define boundaries of midpalm space deep infection, symptoms/signs and treatment

A

MIDPALM - deep to flexors

Floor - Volar IO and MC 3,4,5

Roof - flexor sheaths 3,4,5 and palmar aponeurosis

Radial - vertical septum at D3 MC

Ulnar - hypothenar septum at D5 MC

Finding - loss of palmar concavity

Tx

I&D with incisoin from D3 webspace to pisiform

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10
Q

Define boudaries of Paronas space, findings and Treatment

A
  • volar wrist b/w PQ and long flexors
  • communicates w radial and ulnar bursa - horseshoe abscess-
  • proximal extend to FDS insertion
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11
Q

What are complications of a hand infection

A

EARLY

  • skin slough
  • extension to adjacent structures - OM, SA, tendon rupture, vessel thrombosis
  • amputation

LATE

  • recurrence
  • stiffness
  • degenrative arthritis
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12
Q

What is your management of a felon

A

= subcutaneous abscess of the finger pulp

Compx: OM, skin/pulp necrosis

Tx - I&D - incise on non-dominent side, break apart septae, keep intact flexor sheath, Abx, pack tid

–> can also consider longitudinal incision over most pointing aspect of felon

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13
Q

What is your management of a herpetic whitlow

A

= vesicles 2’ to HSV1 (oral) HSV2 (genital)

Dx: Tzank smear of vesicle media or IF anti-HSV Ab

Tx: no I&D, dry gauze, topicla pancyclovir if immunocompromised, acyclovir if prodrome

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14
Q

What is your DDX of acute suppurative flexor tenosynovitis

A
  • gout/psudogout
  • inflammatory tenosynovitia
  • herpetic whitlow
  • felon
  • abscess
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15
Q

What is your management of acute flexor tenosynovitis suppurativa

A

Early

  • IV abx, splint elevate observe and reqeunt reassessment

Late

  • Catheter irrigation - incise prox to A1 distal to A4, irrigate w tid dressing change
  • ABX: ???
  • Early ROM
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16
Q

What is your management of a dog/cat bite

A

History

tetanus

Rabies immunization

Culture

copious irrigation

delayed 1 wound healing

Xray to r/o FB

Abx: amox-clav (clavulin) OR if pen allergy, clindamycin + septra

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17
Q

What bacteria are associated w dog and cat bites?

A

DOG

  • s. aureus, s. viridans
  • bacteroides
  • pasteurella multicoda GNB
  • capnocytphaga canimorsus

CAT

  • Pasteurella multicoda most common

plus similar to above

  • cat scratch - rochalimaea henselea
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18
Q

What is your management of a human bite/fight bite

A

History

Tetanus

Culture

Xray for air in jt/FB

Clavulin OR if pen allergy, clindamycin + septra

I&D if joint involved, packing, delayed extensor repair

* most common pathogens

  • aerobics: s. aureus, epidermidis, strep
  • anaerobic: bacteroides, peptococcus, peptosctreptococcus, Eikenella corrodens GNR,
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19
Q

What is your management of a necrotizing fasccitis

A
  • ABCs, ICU consult
  • Culture wound/blood
  • CBC, lytes Cr, LFT, CK, INR/PTT, lactate
  • Or - debridement devitalized tissue, repeat OR 24-48hrs later
  • IV abx - vanco+piptazo+clinda. Use 900mg IV q8h clinda for anaerobe, 4mu q4h penicillin for GAS
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20
Q

What are complications of septic arthritis

A
  • Stiffness, adhesions
  • OM
  • degenerative arthritis
  • boutonniere, mallet (pus erodes dorsally)
  • amputation
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21
Q

What will you send from sample for chronic wound to determine etiology

Study These Flashcards
A
  • 1/2 in formalin (histo)
  • 1/2 not in formalin for 8pack micro diagnostic work-up:
  • ​Smears and stains:
    • Gram stain
    • AFB (ziehl neelsen)
    • Fungal stain (KOH)
  • Culture and sensitivity
    • aerobic
    • anaerobic
    • tuberculous mycobacteria at 37’
    • non-tuberculous mycobacteria at 30’ (M.marinum) and at 42 (M.xenopi)
    • Mycotic culture media (Sabouraud dextrose agar) for sporotrichosis
22
Q

What is your management of cat scatch disease?

Study These Flashcards
A
  • Bartonella
  • Inoculation 1-3wks
  • lymphangitis, regional LAD
  • Self limiting
23
Q

What is your management of Actinomycosis?

Study These Flashcards
A
  • Actinomycosis Israelii
  • H&N, oral lesion ->abscess, + sinuses +sulfur yellow granules expressed, INVASIVE
  • Biopsy, Penicillin 6-12mths
24
Q

What is your management of Tularemia?

Study These Flashcards
A
  • Francisella Tularensis
  • Hx of animal bite non responisve to regular treatment w clavulin - >papule to ulceration/necrosis/lymphangitis
  • Tx: streptomycin/gentamycin
25
What necrotizing infection occurs from seawater contact/contamination?
* Vibrio vulnificans -\> necrotizing soft tissue infection - GN anaerobic rod * Tx: surgical debridement, +/- fasciotomies, DOXYCYCLINE
26
What is your treatment of onychomycosis?
* Tinea infection - Trichophytan * nail thickening/seperation - occurs in DM/immunosuppressed/scleroderma * Dx: KOH of scrapings * Tx: antifungals topical, removal nail if persistent
27
What is your differential of a ulcerated verrucous nodule with lymphangitis wks-mths post injury, Hx of farming/gardening?
DDX * nocardiosis (dirt/soil) * tularemia (animla contact) * atypical mycobacteria * sporotrichosis schenckii (gardening)
28
What is your management of sporotrichosis?
* sporothrix schenkii (fungal) * ulcerated raised verrucous nodule with lymphangitis, wks to months post injury while gardening * Dx: culture in Sabourard media * Tx: I&D of abscess if present, + amphotericin or itraconazole
29
What is your management of aspergillosis
* Aspergillosis funigatis (hyphae) * necrotizing ulcer - usually at IV site - in immunocomp. * DDx nocardia, mucor * Dx: KOH prep * Tx - debridement w clear margins and amphotericin B
30
What is your management of mucormycosis
* Mucorales rhizopus/rhizomucor * Triad: DM, gangrene, thrombosis + black discharge * Dx: biopsy * Tx:debridement + IV amphotericin
31
What is your management of mycobacterial infection?
* MOST COMMON CHRONIC HAND INFECTION * TYPICAL: M. tuberculosis, bovis * ATYPICAL: M. marinum, Kansaii * Chronic granuloma + caseation * Dx: biopsy, culture (ZIehl Niessen stain) * Tx: Isoniazid, Rifampin, Ethambutal, Pyrazinamide
32
Where can tuberculosis infection occur and how does tx differ?
* Cutaneous TB (most common site) * M. marinum, tuberculosis * TB tenosynovitis * M. Marinum most common * TB arthritis * M. Marinum most common * TB osteomyelitis
33
What is your management of cutaneous TB?
* M. tuberculosis/marinum - Typical Myco infx * Hx of fresh water exposure * pustules on digits, LAD * Dx: skin biiopsy for ZN stain (AFB), C&S for mycobac * Tx: * Anti-tb Tx with Isoniazid, Rifampin, Ethambutal, Pyrazinamide
34
What is your management of TB tenosynovitis
* M. Marinum most common * mimicks RA synovitis, commonly on flexors * Dx. biopsy for AFB, C&S * Tx: Synovectomy, Anti TB Tx: isoniazid, rifampin, ethambutal, pyrazinamide
35
What is your management of TB arthritis and osteomyelitis?
* M. Marinum most common * WRIST most common for arthritis- with _little pain_, mainly swelling and decreased ROM - subchondral erosions draining sinuses * MC and Phalanges most common for OM - bone loss, cystic lesions, pathologic fractue * Tx arthritis: control infection with antiTB meds then arthrodesis or arthorplasty * Tx OM: Anti TB meds
36
How do you classify fungal infections of the hand
By location * cutaneous (skin, nail) * Subcutaneous (sporotrochosis, chronic paronychia) * deep (mucomycosis)
37
What are three cardinal signs of Hansen's Diseasae (HD) - leprosy
* Anesthetic skin patch * Nerve thickening * hypopigmented skin lesions (nodules)
38
What is the pathophysiology of HD?
* Mycobacteria leprae, nasal droplet transmission * invade and proliferate in Schwann cells * causes mononeuritis multiplex * ulnar\>median\>radial * infectious neuropathy, immune neuropathy, compressive neuropathy * immune sys eradicates bacteria and repalces neural tissue with hyalinized fibrous tissue = nerve thickening * incubation 2-3yrs
39
How do you classify and diangose HD?
According to hosts immune response to M. leprae * Tuberculoid (high immunity) * Lepromatous (low immunity) * borderline (unstable/intermediate immunity) Skin biopsy for dx * granulomas, thickened nerves * stain AFB
40
How do you treat HD
* Eradicate M. leprae - Multidrug therapy - dapsone, rifampin, clofazinime x1yr * pain management - n. decompression, NSAIDS, gabapentin * prevention further nerve damage- steroids * restore sensation - n. transfer * restore function - ulnar n defomrity - claw hand - most common * psychiatric support
41
How do you define osteomyelitis?
def. inflammation of bone secondary to pyogenic organism, leading to bone destruction and subsequent new bone formation
42
What is an involucrum, a sequestrum, osteitis and brodies abscess
* Involucrum: layer of newly formed living bone over area of necrotic bone * Sequestrum: area of necrotic bone - defines chronic OM * Osteitis: infected bone cortex * Brodies abscess: localized focus of infected bone following a subperiosteal infection
43
How do you classify OM
By etiology * hematogenous spread (peds) * contiguous spread form ST (vascular insufficiency - DM.PVD) * inoculation (post trauma/iatrogenic) By chronicity * acute: within 2wks of disease and before sequestrae develop * subacute - 1-2 months * chronic \>3months
44
What bacteria are associated with different OM etiologies?
* Post-trauma = s. aureus, epidermidis * Open F# = GNB, anaerobes * Fresh water/pool - m.marinuum * Sickle cell = salmonella * soil = sporotrichosis, enterobacter * foot - pseudomonas
45
List 4 factors protective against development of OM in post traumatic patient
* adequate debridement * stabilization * dead space obliteration * early soft tissue coverage (5-7days)
46
What is your work-up for dx of OM?
* Bone biopsy - before abx or 48hrs after stopping * Blood work - wbc, crp, esr, * Investigations * Xray 1st - need 50% bone loss to see abnormality * CT * MRI - more sensitive butmust be \>12mth and no hardware * scintigraphy - can distinguish healing fractue from infected non union, subclincial OM
47
What are features of OM on Xray and CT?
Xray * periostitis * involucrum formation * cortical lucency CT * cortical defects * sequestra * fistula
48
What are your treatment goals and principles for OM?
GOALS * Eradicate infection * Dead space obliteration * SST coverage * Fracture union * Function PRINCIPLES * Sugical debridement of all infected/devitalized tissue/bone + removal of hardware if fractur healed * Reconstruction of bone and ST * ST: Muscle flap - deadspace/vascular * Bone - exfix/1' graft or 2' graft * \<1.5cm defect - 1' graftw cancellous bone * if 2', wait 3-6mths and place PMMA Abx beads * IV abx 6wks and until all clinical signs improve * **if hardware in place, and s. aureux infection -\> rifampin + ciprofloxacin** * Amputation - if all tx fails and cannot restore fx
49
What is your treatment algorith for acute infection after ORIF
* Bone not healed, hardware stable * Abx and leave hardware until union and clinically improved, then remove hardware * Bone not healed, hardware unstable * Abx, remove hardware and externally stabilize and plan for 2' recon once infx clear * Bone healed, hardware stable * Abx, remove hardware, control dead space
50
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