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).
Table 182-1 Kanavel 4 Cardinal Signs of Flexor Tenosynovitis |Favorite Table|Download (.pdf)
Table 182-1 Kanavel 4 Cardinal Signs of Flexor Tenosynovitis
Tenderness over the entire length of the flexor tendon sheath
Symmetric finger swelling along the length of the tendon sheath
Intense pain with passive extension
Flexed posture of the involved digit at rest to minimize pain
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 ...