Chapter 182. Infectious and Noninfectious Disorders of the Hand

Rest, elevation, and draining any pus are the mainstays of treatment for many conditions of the hand. This helps to decrease inflammation, avoid secondary injury, and prevent spread of any existing infection. The optimal position for splinting is the position of function: wrist in 15° extension, metacarpal-phalangeal (MCP) joint in 50° to 90° flexion, proximal interphalangeal (PIP) joint in 10° to 15° flexion, and distal interphalangeal (DIP) joint in 10° to 15° flexion.

Cellulitis is a superficial infection presenting with localized warmth, erythema, and edema. The absence of tenderness on deep palpation and range of motion helps exclude deep space involvement.

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

Deep space infections involve the web or midpalmar space. Web space infection presents as dorsal and volar swelling of the web space causing separation of the affected digits. Midpalmar space infection occurs from spread of a flexor tenosynovitis or penetrating wound to the palm causing infection of the radial or ulnar bursa of the hand.

Closed fist injury is essentially a human bite wound to the MCP joint that results from punching an individual in the teeth. Risk of infection spreading along the extensor tendons is high. Wounds penetrating the skin should be explored, irrigated, and allowed to heal by secondary intention. When inspecting for extensor tendon injury, it is essential to consider the position of the hand at the time of injury. Extensor tendon repair is delayed until the risk of infection has passed.

Paronychia is an infection of the lateral nail fold. If there is no pus, treat with warm soaks, elevation, and antibiotics if warranted. A simple paronychia is drained by lifting the nail fold with a needle or number 11 blade to drain the abscess. If pus is seen beneath the nail, a portion of the nail may have to be removed and packing placed for adequate drainage. Avoid injury to the nail bed. Recheck the wound in 24 to 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. The incision should remain within the borders of the DIP joint crease proximally and the base of the phalangeal tuft distally. Incise deep enough to extend across the entire finger pad to divide the septae at the bony insertions. Unless there is a pointing abscess, the radial aspect of the index and middle fingers and the ulnar aspect of the thumb and small finger, should be avoided. If there is a pointing volar abscess, a longitudinal volar incision is used. Pack the wound. Splint the hand in the position of function. Recheck in 24 to 48 hours, pull the packing, and begin warm soaks.

Herpetic whitlow is a viral infection of the fingertip. Clinically, it may present similar to a felon, but vesicles are present. Immobilize, elevate, and protect with a dry dressing to prevent transmission. Antiviral agents may shorten the duration.

Table 182-2 summarizes recommended antibiotic therapy for common hand infections.

Tendonitis and tenosynovitis are usually due to overuse. Examination reveals tenderness over the involved tendon. Treat with immobilization and nonsteroidal anti-inflammatory drugs (NSAIDs).

Trigger finger is a tenosynovitis of the flexor sheath where inflammation or scarring results in impingement and snap release of the tendon. This occurs as the finger is extended from a flexed position. Steroid injection may be effective in early stages. Definitive treatment is surgery.

DeQuervain tenosynovitis involves the extensor pollicis brevis and abductor pollicis tendons. Pain occurs at the radial aspect of the wrist and radiates into the forearm. Finkelstein test is diagnostic: the patient grasps the thumb in the fist and deviates the hand ulnarly, reproducing the pain. Treat with a thumb spica splint, NSAIDs, and referral.

Carpal tunnel syndrome results from compression of the median nerve by the transverse carpal ligament. The cause is usually edema secondary to overuse, pregnancy, or congestive heart failure. Pain in the median nerve distribution tends to be worse at night. On examination, pain may be reproduced by tapping over the nerve at the wrist (Tinel sign) or by holding the wrist flexed maximally for >1 min (Phelan sign). Treat with a wrist splint, NSAIDs, and referral.

Dupuytren contracture results from fibrous changes in the subcutaneous tissues of the palm, which may lead to tethering and joint contractures. Refer to a hand surgeon.

Ganglion cyst is a cystic collection of synovial fluid from a joint capsule or tendon sheath. Treat with NSAIDs and referral.