Courtesy: Sreenadh Gella, FRCSOrth, Birmingham, UK
Hand Space Infections
Overview
- Hand infections may involve potential anatomical spaces
- These spaces become clinically evident only when filled with:
- Pus
- Fluid
- Inflammatory exudate
Disease Progression
- May begin as cellulitis
- Can:
- Resolve with treatment
- Progress to abscess formation
High-Risk Patients
- Diabetes mellitus
- Intravenous drug use
- Immunosuppression
Anatomical Classification of Hand Spaces
Superficial Spaces
- Pulp spaces
- Web spaces
- Dorsal subcutaneous space
- Dorsal subaponeurotic space
Deep Spaces
- Flexor tendon sheaths
- Radial bursa
- Ulnar bursa
- Mid palmar space
- Thenar space
- Hypothenar space
Clinical Insight
- Deep infections:
- Less obvious early
- More severe
Common Pathogens
- Staphylococcus aureus infection (most common)
Bite-Related Organisms
- Human bites – Eikenella
- Animal bites – Pasteurella
- Often polymicrobial
Flexor Tendon Sheath Infection
Causes
- Penetrating injury
- Direct inoculation
- Spread from adjacent tissue
Anatomical Spread
- Little finger – ulnar bursa
- Radial and ulnar bursae may communicate
- Can spread to:
- Forearm
- Deep spaces
Clinical Features (Kanavel Signs)
- Fusiform swelling
- Finger held in flexion
- Pain on passive extension
- Tenderness along tendon sheath
Treatment
Early Stage
- Intravenous antibiotics
- Close observation
Definitive Treatment
- Surgical drainage + washout
Techniques
- Immediate drainage
- Continuous irrigation (24–48 hours)
Complications
- Finger stiffness
- Recurrent infection
- Scar formation
- Need for further surgery
Poor Prognostic Factors
- Diabetes
- Bite injuries
- Subcutaneous pus
- Digital ischemia
Late Complications
1. Tendon Necrosis / Rupture
- May require:
- Two-stage reconstruction
2. Stiffness
- Initial:
- Intensive physiotherapy (6 months)
- Persistent:
- Surgical release (limited results)
Infection of Space of Parona
- Spread from flexor sheath to forearm
Significance
- Surgical emergency
Treatment
- Surgical drainage
- Carpal tunnel release (if required)
Lymphangitis
Features
- Red streaks proximally
- Associated cellulitis
Cause
- Commonly streptococcal
Management
- Medical (antibiotics)
- Surgery only if deeper infection suspected
Pulp Space Infection (Felon)
Cause
- Penetrating injury
Complication
- Increased pressure — tissue necrosis
Special Note (Children)
- Higher risk of osteomyelitis
- Early drainage recommended
Surgical Incisions
Preferred
- Lateral longitudinal
- Oblique
Avoid
- Fish-mouth
- U-shaped
- H-shaped
- Transverse pulp incisions
Deep Palmar Space Infections
1. Thenar Space Infection
Clinical Features
- Thumb abducted
- Fingers extended
- Palmar swelling
Spread
- First web space
- Proximal tendon sheath
Treatment
- Early surgical drainage
2. Mid Palmar Space Infection
Clinical Features
- Fingers flexed
- Thumb adducted
- Dorsal swelling
Diagnosis
- Imaging (USG/MRI)
- Surgical exploration if needed
3. Hypothenar Space Infection
- Rare
- Pain with little finger movement
Treatment
- Surgical drainage
Nail Unit Infections
Types
- Acute paronychia
- Chronic paronychia
Chronic Paronychia
Cause
- Often fungal (Candida)
Features
- Long-standing inflammation
- Nail deformity
- No acute pus
Treatment
- Marsupialization
- Swiss roll technique
Herpetic Whitlow
- Viral infection (HSV)
- Vesicles near nail
- Nail plate usually spared
Glomus Tumor
- Painful subungual lesion
- Severe localized pain
- Nail fold appears normal
Web Space Abscess
Clinical Feature
- Fingers held in abduction
Treatment
- Dual incision:
- Dorsal
- Palmar
Collar Button Abscess
Definition
- Dual abscess:
- Palmar + dorsal
- Connected through web space
Treatment
- Drain both sides
Key Takeaways
- Hand infections can spread rapidly through anatomical spaces
- Early diagnosis and drainage are critical
- Deep infections are dangerous and often subtle initially
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