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Drainage of pus, immobilization, elevation, and antibiotics are the mainstays of treatment for many conditions of the hand. This helps to decrease inflammation, avoid secondary injury, and prevent extension of any infection. Optimal splinting is in the position of function: wrist in 15° to 30° extension, metacarpophalangeal (MCP) joints in 50° to 90° flexion, and the interphalangeal joints in 10° to 15° flexion.


Cellulitis is a superficial infection presenting with localized warmth, erythema, and edema. Absence of tenderness on deep palpation and nonpainful digit range of motion help to exclude deep space involvement.

Flexor tenosynovitis is a surgical emergency diagnosed on examination (Table 182-1).

Table 182-1

Kanavel’s Four Cardinal Signs of Flexor Tenosynovitis

Deep space infections involve the thenar, web, or midpalmar space, or the radial or ulnar bursa. Infection occurs from spread of a flexor tenosynovitis or a penetrating wound. The palm is tender to palpation and range of motion of the digits is painful where the flexor tendons course through the area of infection. Swelling from web space infection causes separation of the affected digits. Deep space infections often require operative drainage.

Closed fist injury is essentially a bite wound to the MCP joint that results from a punch to the teeth. There is high risk of infection to the skin, tendon, joint, bone, and deep space. Wounds penetrating the skin require exploration, irrigation, prophylactic antibiotics, and healing by secondary intention. Wounds with established signs of infection require IV antibiotics and hand surgery consult for consideration of operative intervention.

Paronychia is an infection of the lateral nail fold. If there is no pus, treat with warm soaks, elevation, and antibiotics if warranted. A paronychia is drained by lifting the nail fold with a flat blade. If pus is seen beneath the nail, a portion of the nail may need removal and packing placed for adequate drainage. Recheck within 48 hours, pull the packing, and begin warm soaks.

Felon is an infection of the pulp space of the fingertip. Incision and drainage are by the lateral approach to protect the neurovascular bundle. Do not incise the distal end of the finger pad. Do not extend the incision proximally to the flexor crease of the distal interphalangeal joint. More extensive through-and-through or “hockey stick” incisions are not indicated. Bluntly dissect the septae to ensure complete drainage. If there is a pointing volar abscess, a longitudinal volar incision is used. ...

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