Complications of infection: Infections are always considered a complication, and have common presentations in the hand.
Missed diagnosis of infection: Herpetic whitlow, a viral skin infection of the finger pulp, is commonly misdiagnosed as an abscess, felon or paronychia. Diagnosis is suggested by a prodrome of pain, and early signs of tiny vesicles and itching. Incision and drainage only prolongs recovery and should be avoided if possible. Missed deep infections (ctpus.htm) of the hand are possible because the dense fibrous compartments within the hand mask swelling and contour changes from deep abscess. Diagnosis is made based on suspicion, with the caveat that throbbing hand pain which keeps the patient awake at night associated with any other signs of infection indicating deep hand abscess until proven otherwise. Missed severe contamination has been discussed in the previous section on complications of missed complex wounds.
Complications of infections
and
infections prone to complications: Unsatisfactory results are more
likely when hand infections involve anaerobes, Eikenella corrodens or human
bites (CH). Quantitative cultures
are the single most sensitive and specific predictor of infection following
microvascular free flap reconstruction of complex extremity injuries, and
should be a routine part of this form of treatment. Complex wounds which
are found to have greater than 1000 organisms per cubic centimeter at the
time of free flap closure should be treated with return to the operating
room, flap elevation, repeated debridement and closure (DJ).
Atypical infections (CH) may involve
subcutaneous tissues or more commonly tendon sheath spaces. Mycobacteria
species, most commonly mycobacterium marinum produce slowly progressive
hand infections. Deep space infections from either typical or atypical
infection usually follow puncture wounds contaminating tendon sheath compartments
or joint spaces. The most vulnerable areas where apparently trivial wounds
can contaminate deep spaces are the flexion greases of the fingers and
the extension creases on the dorsum of the fingers. Diabetic hand infections,
particularly in patients with diabetic chronic renal failure, are common,
frequently severe and often result in tissue loss. Hand infections in such
patients are frequently more severe than they appear by clinical examination,
and the surgeon must have a low threshold for early extensile surgical
debridement of the entire zone of inflammation (CA).
Gram negative infections are common, and amputation is a common consequence.
Pyarthrosis
and septic arthritis of the small joints of the hand is more likely to
achieve a poor results if presenting after ten days from injury, or when
associated with severe trauma (DB).
The most common scenario for small joint infection of the hand involves
clenched fist bite injury (boxer4.htm).
Hematogenous
seeding resulting in implant infection (1400001S.htm,
1351400s.htm)
is an uncommon but catastrophic problem justifying prophylactic antibiotics
during high risk procedures for patients who have implants such as silastic
joint spacers which maintain a permanent open space around the implants.
Tetanus may develop following hand injuries (BO),
and is most common in the context of parenteral drug abuse. More commonly,
deep soft tissue infections from parenteral drug abuse are polymicrobial,
and may present as gas forming infection (ivdagas.htm),
necrotizing infection, or suppurative thrombophlebitis
(BP). Treatment requires excision of
the involved area, wide drainage, repeated debridement, and appropriate
parenteral antibiotics.
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