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Barger J, Hoyer RW. Fingertip Infections. Orthop Clin North Am 2024; 55:265-272. [PMID: 38403372 DOI: 10.1016/j.ocl.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
The fingertip is the interface between humans and the world, including the various thorns, dirty needles, and other hazards to be found there. It is unsurprising that this is the site where hand infections most frequently occur. Although commonly encountered by hand surgeons and other physicians, fingertip infections have several mimics, and diagnosis and management is not always straightforward. Early diagnosis and treatment are key to success. As with all infections, they are more common and are more aggressive in immunosuppressed patients. This article reviews fingertip anatomy, common and uncommon fingertip infections and their mimics, and recommendations for management.
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Affiliation(s)
- James Barger
- Indiana Hand to Shoulder Center, Indianapolis, IN, USA
| | - Reed W Hoyer
- Indiana Hand to Shoulder Center, Indianapolis, IN, USA.
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Allen M, Gluck J, Benson E. Renal disease and diabetes increase the risk of failed outpatient management of cellulitic hand infections: a retrospective cohort study. J Orthop Surg Res 2023; 18:420. [PMID: 37301849 DOI: 10.1186/s13018-023-03911-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Hand infections are heterogeneous, and some may undergo successful outpatient management. There are no strict guidelines for determining which patients will likely require inpatient admission for successful treatment, and many patients succeed with outpatient therapy. We sought to determine risk factors for failed outpatient management of cellulitic hand infections. METHODS We performed a retrospective review of patients who presented to the Emergency Department (ED) for hand cellulitic infections over five years, from 2014 to 2019. Vital signs, lab markers, Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Measure (ECM), and antibiotic use were investigated. Discharge from the ED without subsequent admission was considered an outpatient success, while admission within 30 days of the prior visit was considered a failure. Continuous variables were compared with Welch's t test, and categorical data with Fisher's exact tests. Multivariable logistic regression was performed on comorbidities. Multiple testing adjustment was performed on p-values to generate q-values. RESULTS Outpatient management was attempted for 1,193 patients. 31 (2.6%) infections failed treatment, and 1,162 (97.4%) infections succeeded. Attempted outpatient treatment was 97.4% successful. Multivariable analysis demonstrated higher odds of failure with renal failure according to both CCI (OR 10.2, p < 0.001, q = 0.002) and ECM (OR 12.63, p = 0.003, q = 0.01) and with diabetes with complications according to the CCI (OR 18.29, p = 0.021, q = 0.032). CONCLUSIONS Outpatient treatment failure was higher in patients with renal failure and complicated diabetes. These patients require a high index of suspicion for outpatient failure. These comorbidities should influence consideration for inpatient therapy though most patients can undergo successful treatment as outpatients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Michael Allen
- Community Memorial Health System, 147 Brent St, Ventura, CA, 93003, USA.
- Ventura County Medical Center, 300 Hillmont Ave, Ventura, CA, 93003, USA.
| | - Joshua Gluck
- Community Memorial Health System, 147 Brent St, Ventura, CA, 93003, USA
- St. John's Regional Medical Center, 1600 N Rose Ave, Oxnard, CA, 93030, USA
| | - Emily Benson
- Community Memorial Health System, 147 Brent St, Ventura, CA, 93003, USA
- Ventura County Medical Center, 300 Hillmont Ave, Ventura, CA, 93003, USA
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Lemme NJ, Li NY, Testa EJ, Kuczmarski AS, Modest J, Katarincic JA, Gil JA. A Nationwide Epidemiological Analysis of Finger Infections Presenting to Emergency Departments in the United States From 2012 to 2016. Hand (N Y) 2022; 17:302-307. [PMID: 32354232 PMCID: PMC8984722 DOI: 10.1177/1558944720915614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: There is a paucity of literature exploring the epidemiology of finger infections presenting to emergency departments (EDs) on a national scale. The purpose of this study was to determine the national incidence of and risk factors for finger infections. Methods: Finger infections presenting to EDs between 2012 and 2016 were identified in the National Electronic Injury Surveillance System database. Finger infections were characterized by mechanism and type, with subanalyses for sex, race, and age. Results: Over this 5-year period, finger infections accounted for 80 519 visits to EDs in the United States. The annual incidence increased significantly from 4.4 per 100 000 person-years in 2012 to 6.2 in 2016. The 3 most common causes of finger infections were nail manicuring tools, knives, and doors. The most common diagnosis was finger cellulitis (46.3%). Significantly more men developed finger infections than women (relative risk of 1.4). The highest overall incidence was observed in 40- to 59-year-old men (7.8 per 100 000 person-years). Tenosynovitis resulted in the largest proportion of admissions (25%). Conclusions: We have demonstrated a rising incidence of finger infections presenting to EDs, with 40- to 59-year-old patients most at risk. The most common mechanism was the use of nail manicuring tools, such as nail clippers. Patient education may decrease finger infection incidence from these activities, and early detection of finger infections may be crucial to minimizing hospital admissions and invasive treatments.
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Affiliation(s)
- Nicholas J. Lemme
- Alpert Medical School of Brown
University, Providence, RI, USA,Nicholas J. Lemme, Department of Orthopaedic
Surgery, Alpert Medical School of Brown University, 593 Eddy Street, Providence,
RI 02903, USA.
| | - Neill Y. Li
- Alpert Medical School of Brown
University, Providence, RI, USA
| | - Edward J. Testa
- Alpert Medical School of Brown
University, Providence, RI, USA
| | | | - Jacob Modest
- Alpert Medical School of Brown
University, Providence, RI, USA
| | | | - Joseph A. Gil
- Alpert Medical School of Brown
University, Providence, RI, USA
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Homogenization of the management of acute paronychia with abscess formation within the context of an evaluation of professional practices. Orthop Traumatol Surg Res 2021; 107:102982. [PMID: 34102333 DOI: 10.1016/j.otsr.2021.102982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/18/2020] [Accepted: 09/15/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION There is no consensus in the literature, or even within the same team, on the most appropriate treatment option for acute paronychia with abscess formation. The performance of an evaluation of professional practices (EPP) using a clinical audit measures the quality of our practices with the aim of standardizing them. Therefore, the primary objective of this study was to develop a clinical pathway for the management of acute paronychia with abscess formation. The secondary objectives were to evaluate our professional practices using a clinical audit before and after the dissemination of the clinical pathway and then recommend strategies for improving our management of acute paronychia with abscess formation. MATERIALS AND METHODS A working group was established that designed an audit grid comprised of 15 items. Thirty patients (Group 1) who had an acute paronychia with abscess formation were included and their health records were analyzed using this audit grid. The working group then developed a clinical pathway for the management of acute paronychia with abscess formation. Thirty new patients (Group 2) were included after the dissemination of this clinical pathway and their records were analyzed using the same audit grid. RESULTS Our clinical pathway for the management of acute paronychia was validated by the local infectious disease committee of our university hospital center. The difference between groups 1 and 2 was significant (p<0.05) for eight items. There was no significant difference in the rate of surgical revision between the two groups. DISCUSSION This EPP enabled us to develop a clinical pathway that detailed the processes for managing acute paronychia with abscess formation, and in particular it provided indications for antibiotic therapy and its limitations. LEVEL OF EVIDENCE IV, retrospective study.
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Langer MF, Grünert JG, Spies CK, Ueberberg J, Oeckenpöhler S, Wieskötter B. [Paronychia and Felons - Surgical Treatment]. HANDCHIR MIKROCHIR P 2021; 53:245-258. [PMID: 34134157 DOI: 10.1055/a-1472-1933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Infections of the distal phalanx are the most common of all hand infections. There are dorsal localised infections, which develop in the area of the nail and are called paronychia, and palmar infections, which affect the fingertip and are the typical felons. The acute paronychia must be specifically opened depending on the site of infection. This requires precise anatomical knowledge of nail structure. Chronic paronychia usually have other causes and treatment is much more difficult. Felons are often extremely painful. There is a complex system of fibrous septa and swelling is limited. If the septa are destroyed a spread into the bones or the flexor tendon sheath is possible.
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Affiliation(s)
- Martin F Langer
- Universitätsklinikum Münster; Klinik für Unfall-, Handund Wiederherstellungschirurgie
| | - Jörg G Grünert
- Kantonsspital St. Gallen, Klinik für Plastische Chirurgie und Handchirurgie
| | | | - Johanna Ueberberg
- Universitätsklinikum Münster; Klinik für Unfall-, Handund Wiederherstellungschirurgie
| | - Simon Oeckenpöhler
- Universitätsklinikum Münster; Klinik für Unfall-, Handund Wiederherstellungschirurgie
| | - Britta Wieskötter
- Universitätsklinikum Münster; Klinik für Unfall-, Handund Wiederherstellungschirurgie
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Dorfmann A, Carmès S, Kadji O, Uzel AP, Dumontier C. Advanced finger infection: more frequent than expected and mostly iatrogenic. HAND SURGERY & REHABILITATION 2021; 40:326-330. [PMID: 33639291 DOI: 10.1016/j.hansur.2020.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 12/02/2020] [Accepted: 12/13/2020] [Indexed: 11/25/2022]
Abstract
Some patients present at an advanced stage of their fingertip infection with an extension of the infection in anatomical spaces or into fragile structures. One hundred and twenty-five patients have been operated on for a finger infection. Forty-one patients (33%) have been treated at the "complication" stage, while 84 cases (67%) were considered "non-complicated". The delay between initial injury and the surgical treatment was 12 days in the "non-complicated" group versus 30 in the "complication" group (p < 0.001). Osteitis (39% of the complications), and flexor sheath infection (37%) were the most frequent complications. Prescribing preoperative antibiotics increases the risk of being in the "complicated" group at p = 0.09. One hundred and thirteen patients (90.4%) were cured of their infection after a single operation. Neither the cause of infection, nor the type of germ or associated diabetes increased the risk of complication in our series. A better education of the first interveners (general practitioner or emergency doctor) in hand infection care could reduce the rate of complication allowing a faster access to hand surgeons.
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Affiliation(s)
- A Dorfmann
- Orthopedic Department, CHU de Pointe à Pitre, Les Abymes, 97139 Guadeloupe, France
| | - S Carmès
- Hand Center, Clinique Les Eaux Claires, ZAC Moudong Sud, 97122 Baie-Mahault, Guadeloupe - French West Indies, France
| | - O Kadji
- Hand Center, Clinique Les Eaux Claires, ZAC Moudong Sud, 97122 Baie-Mahault, Guadeloupe - French West Indies, France
| | - André-Pierre Uzel
- Orthopedic Department, CHU de Pointe à Pitre, Les Abymes, 97139 Guadeloupe, France
| | - C Dumontier
- Hand Center, Clinique Les Eaux Claires, ZAC Moudong Sud, 97122 Baie-Mahault, Guadeloupe - French West Indies, France.
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Abstract
The fingertip is the most common site of infections in the hand, which frequently are encountered by surgeons, dermatologists, and emergency and primary providers. Their mismanagement may have serious consequences. This review discusses the unique anatomy of the volar fingertip pulp and perionychium and reviews pathophysiology and treatment of acute and chronic paronychia, including the decision for surgical versus medical management, choice of antibiotics, incisional techniques, and postincisional care. Felons and the evidence regarding their management are reviewed. Several infectious, rheumatologic, and oncologic conditions that may mimic common fingertip infections and about which the managing provider must be aware are presented.
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Affiliation(s)
- James Barger
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, MGH Orthopaedic Hand Surgery, Yawkey Center for Outpatient Care, 55 Fruit Street, Suite 2C, Boston, MA 02114-2696, USA
| | - Rohit Garg
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, MGH Orthopaedic Hand Surgery, Yawkey Center for Outpatient Care, 55 Fruit Street, Suite 2C, Boston, MA 02114-2696, USA
| | - Frederick Wang
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, MGH Orthopaedic Hand Surgery, Yawkey Center for Outpatient Care, 55 Fruit Street, Suite 2C, Boston, MA 02114-2696, USA
| | - Neal Chen
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, MGH Orthopaedic Hand Surgery, Yawkey Center for Outpatient Care, 55 Fruit Street, Suite 2C, Boston, MA 02114-2696, USA.
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