Non-traumatic hand disorders

Cellulitis

• Mild-moderate: Flucloxacillin (staph/strep cover)
  • Clindamycin 450mg q8h for 7-10 days if MRSA risk or allergic
• Severe
  • IV Flucloxacillin
    • Lincomycin 600mg q8h OR Vancomycin 25-30mg/kg IV loading then 15mg/kg q12h if MRSA or allergic
• MRSA risk in prisoners, immunosuppressed, IVDU, homeless or previous isolation of organism
• After handling fish or saltwater 
  • Risk of Vibrio, Klebsiella, GAS, S. aureus and Enterobacter
  • Ceftazidime and doxycycline proven helpful
• Freshwater (Aeromonas)
  • Ciprofloxacin 12.5mg/kg (500mg) q12h PO or 10mg/kg (400mg) IV q12h in addition to above

Flexor tenosynovitis

• Surgical emergency
• Kanavel’s four cardinal signs
  • Percussion tenderness over entire length of sheath
  • Uniform swelling
  • Intense pain with passive extension
  • Flexed posture of digit at rest to minimise pain
• Usually S. aureus but may be polymicrobial
• Consider gonorrhoea if recent STI
• Start IV therapy and get consult – PipTaz + Vanc if high-risk

Deep space infections

• Deep space infection often misdiagnosed as dorsum of hand cellulitis
• Must examine volar surface of hand for tenderness, induration and fluctuance
• ROM of digits may yield marked pain
• S. aureus and Strep most commonly
• IV PipTaz +- Vanc if at risk

Closed fist injuries

• Fight-bite infections
• Tend to involve multiple planes and spread rapidly to adjacent compartments
• Skin, extensor tendons, joint space, bone and surrounding deep spaces often involved
• X-ray will detect fracture or foreign material (incl. tooth fragments) and/or air in joints
• Mostly streptococcus, S. aureus, Eikenella, Fusobacterium, Peptostreptococcus and Candida (usually polymicrobial)
• If no infection (prophylactic) – Thorough washout and augmentin
• If infection – PipTaz + ortho consult for washout in OT

Paronychia

• Infection of lateral nail fold
• Can extend to cuticle (eponychium)
• Usually due to nail biting, manicures or embedded lateral nails (hang-nails)
• Mostly aerobic + anaerobic polymicrobial
• If fluctuant – drain
• If not fluctuant – warm soaks, elevation and Fluclox +- vanc for surrounding cellulitis
  • Minor infections can be treated with elevation of perionychium or eponychium with a flat probe to allow drainage
• If fluctuant – Digital block, incision of most flutuant area
• Severe infections with pus beneath nail require removal of lateral or proximal nail
• Only need antibiotics if surrounding cellulitis
• Need review within 48 hours

Felon

• Subcutaneous pyogenic infection of pulp space
• Septa of finger pad compartmentalise infection so get very red, tense, painful distal pulp space
• Can spread to flexor tendon sheath if not treated adequately or to underlying periosteum leading to osteomyelitis
• S. aureus mostly + strep, anaerobes, gram-negatives
• Drain infection if fluctuance, tense and swollen
• Unilateral, longitudinal approach spares the sensate volar pad
• Dissect septa to ensure adequate drainage
• Irrigate wound, place sterile dressing and keep elevated with review in 48 hours
• Regular warm soaks keep wound clean and open
• Most felons have associated cellulitis warranting PO antiboitics (fluclox +- cipro or vanc)

Herpetic whitlow

• Viral infection of distal finger from HSV-1 (children with gingivostomatitis) or HSV-2 (adults)
• Healthcare workers and respiratory and dental technicians most at risk
• Finger may be indurated but not tense like a felon
• Do not misdiagnose as felon as I&D can result in secondary bacterial infection and failure to heal
• Resolves without treatment within 3 weeks
• Antivirals can abort recurrent infection and decrease course of protracted cases

Tendinitis and tenosynovitis

• Typically repetitive strain injury of tendons
• Splint in POSI with elevation, NSAID’s and follow-up with LMO or hand surgeon
• Trigger finger
  • Inflammation can lead to flexor tendon nodularity leading to friction and catching, typically at A1 pulley at volar crease at base of each digit
  • A1 pulley is proximal portion of flexor tendon sheath
  • As finger extends, tendon is bound then painful snap felt
  • Treatment is rest, NSAID’s, immoblisation in POSI and referral to hand surgeon
  • Early stages can be treated with corticosteroid injection into tendon sheath although recurrence occurs in 50%
  • Surgical release of A1 pulley is curative

De-Quervain’s stenosing tenosynovitis

• Excessive thumb or wrist use
• Tenosynovitis of extensor pollicis brevis and abductor pollicis tendons in groove of radial styloid
• Finkelstein test – Patient grips thumb in hand and examiner ulnar deviates wrist with subsequent pain
• Immobilise thumb and wrist in splint, with daily removal and ROM exercises
• NSAID’s
• Refer to hand surgeon for persistent cases

Carpal tunnel syndrome

• Often wakes at night with burning pain or tingling
• Numbness when driving car or maintaining wrist in flexion
• Often improves with ‘wringing’ of hands
• Causes
  • Traumatic, haematologic, rheumatologic, anatomic or infectious
  • Commonly overuse, pregnancy, CCF
• Two-point discrimination in median nerve distribution is one of the most useful exam maneuvers
• Tinel’s sign – Tapping volar aspect of wrist over median nerve with subsequent paraesthesia
• Phalen’s sign – More sensitive and specific with reverse prayer for 1 minute
• If motor deficit present – urgent consult
• Otherwise, volar splint to maintain neutral position with NSAID’s for 10-14 days
• If persistent – hand surgeon referral
• Only 5% require revision carpal tunnel release

Dupuytren’s contracture

• Fibroplastic changes of subcutaneous tissues of palm and volar aspect of fingers
• 4^th and 5^th fingers affected earliest
• Mostly men of northern European descent
• Tobacco use, alcohol, DM and repetitive overuse
• Refer to hand surgeon

Ganglion cysts

• Cystic collection of synovial fluid in tendon sheath or joint
• Common often after injury
• Commonly on dorsal/volar wrist, flexor surface of MCP joint or base of nail
• Treatment – Analgesics and NSAID’s
• 1/3 resolve spontaneously
• Refer to hand surgeon if persistent
• Surgery is effective but recurrence occurs in 39%

Last Updated on October 6, 2020 by Andrew Crofton