Factors related to the resolution of treated hand infections

Systematic review of treatment for pyogenic flexor tenosynovitis of the hand

AIMS

Pyogenic flexor tenosynovitis (PFT) comprises 2.5-9.4% of all primary hand infections. Management is variable, including surgical intervention, systemic antibiotics, or both. However, there are no evidence-based treatment guidelines. We conducted a systematic review to determine the best evidence for existing interventions and a meta-analysis to summarise published data quantitatively.

METHODS

MEDLINE and Embase (OVID) databases were searched in January 2023 and March 2024. Screening and data extraction were performed in duplicate. The risk of bias was assessed using National Institute of Health study assessment tools. A protocol is available on PROSPERO (CRD42023411142), and the review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data analysis was performed in RStudio.

RESULTS

24 studies (n = 1108 patients) were included following screening of 2386 abstracts. All were retrospective (18 case series and six cohort studies). Surgical interventions were assessed in 22 studies, combined with specific antibiotic regimes in four studies. Two studies described non-operative management alone. The pooled mean hospital stay for those undergoing operative intervention was 8.3 days (SD 7.5, n = 552), compared to 4.76 days (SD 0.12, n = 58) for non-operative intervention. Two studies reported PROMs (DASH), reporting no difference when comparing operative and non-operative interventions. Most studies were of poor quality (20), with four being fair.

CONCLUSIONS

There is insufficient evidence in favour of one intervention regarding hospital stay or PROMs, including the superiority of operative management or non-operative approaches. Given the prevalence of PFT, management should be guided by robust data. Future experimental studies of surgical techniques and comparisons with non-operative management are warranted.

Predictors of Digital Amputation in Diabetic Patients With Surgically Treated Finger Infections

BACKGROUND

Diabetes is a well-established risk factor for severe digital infection, and patients are more likely to require digital amputation for adequate source control. This study aims to identify factors predictive of digital amputation compared with preservation in patients with diabetes who present with surgically treated finger infections.

METHODS

Current Procedural Terminology (CPT) and International Classification of Diseases Versions 9 and 10 (ICD-9/10) databases from a single academic medical center were queried to identify patients with type 1 or type 2 diabetes mellitus who underwent surgical treatment in the operating room for treatment of a digital infection from 2010 to 2020. Electronic medical records were reviewed to obtain historical and acute clinical variables at the time of hospital presentation. Bivariate and multivariable regression were used to identify factors associated with amputation.

RESULTS

In total, 145 patients (61 digital amputation, 84 digital preservation) met inclusion criteria for this retrospective cohort study. Mean hospital stay was 6 days, and the average patient underwent 2 operations. Multivariable analysis revealed that the presence of osteomyelitis, ipsilateral upper extremity dialysis fistula, end-stage renal disease, and vascular disease each had significant independent predictive value for amputation rather than digital preservation.

CONCLUSIONS

Digital amputation is common in the setting of diabetic finger infection. The 4 variables found to independently predict the outcome of amputation can be understood as factors which decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection. Further study should focus on clinical factors affecting surgical decision making and how the treatment rendered affects patient outcomes.

Contrast Enhanced Computed Tomography in the Diagnosis of Acute Pyogenic Flexor Tenosynovitis

BACKGROUND

The diagnosis of infectious flexor tenosynovitis (FTS) has historically been made based on physical exam using Kanavel's signs. The specificity of these findings has come into question. We looked to evaluate the use of contrast-enhanced computed tomography (CT) in increasing the successful diagnosis of FTS.

METHODS

Two adult cohorts were formed, one of patients with FTS confirmed in the operating room and the second of patients with ICD.10 identified finger cellulitis (FC), without concomitant FTS. Demographics, laboratory values, CT scans, and examination findings were evaluated. Axial CTs were evaluated in the coronal and sagittal planes and tendon sheath/tendon width were measured. The tendon sheath/tendon was recorded as a ratio in the coronal (CR) and sagittal (SR) planes. Continuous and dichotomous variables were analyzed and measures of sensitivity, specificity, and predictivity were calculated. Seventy patients were included, 35 in the FTS cohort and 35 with FC.

RESULT

A higher number of Kanavel signs were present in the FTS group (2.9 vs. 0.5, P < .05), with CR and SR both being significantly larger in the FTS group (P < .05). CR and SR cutoffs ≥ 1.3 provided high sensitivity, specificity, and positive predictive value (PPV) for FTS. Likelihood of FTS increased 5.9% and 5.5% for every 0.1 increase in CR and SR, respectively, with a 14% increase for every additional Kanavel sign.

CONCLUSION

In conclusion, CT ratios are useful in identifying FTS; and when used on their own or in combination with Kanavel's signs, CR and SR objectively improve the diagnosis of FTS.

Renal disease and diabetes increase the risk of failed outpatient management of cellulitic hand infections: a retrospective cohort study

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.

Tenolysis and Salvage Procedures

Complications in flexor tendon repair are common and include tendon rupture, adhesion formation, and joint contracture. Risk factors include preexisting conditions, gross contamination, concurrent fracture, early unplanned loading of the repaired tendon, premature cessation of splinting, and aggressive early active range of motion protocols with insufficient repair strength. Rupture of a repaired tendon should be followed by early operative exploration, debridement, and revision with a four-core strand suture and nonbraided epitendinous suture. Wide-awake flexor tenolysis should be considered when adhesion formation results in the plateaued range of motion, and passive motion exceeds active motion. Two-staged reconstruction is recommended when injury results in excessive scaring, joint contracture, or an incompetent pulley apparatus.

Evaluating the utility of inflammatory markers in the diagnosis of soft tissue abscesses of the forearm and hand

Upper extremity abscesses frequently present to the acute care setting with inconclusive physical examination and imaging findings. We sought to investigate the diagnostic accuracy of inflammatory markers including white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). A retrospective cohort study was performed to identify subjects ≥ 18  years treated with surgical debridement of upper extremity abscesses at our institution between January 2012 and December 2015. In this study, 188 patients were screened, and 72 met the inclusion criteria. A confirmed abscess as defined by culture positivity was present in 67 (93.1 %) cases. The sensitivity of WBC, ESR, or CRP individually was 0.45, 0.71, and 0.81. The specificity of WBC, ESR, or CRP individually was 0.80, 0.80, and 0.40. In combination all three markers when positive had a sensitivity of 0.26 and specificity of 1.0. These values were similar among patients with diabetes and those with obesity. With the highest sensitivity and lowest specificity, CRP exhibited the most utility as a screening test (level IV).

Upper limb infections: A comparison between diabetic and non-diabetic patients

BACKGROUND

Upper limb infections are common among patients with diabetes mellitus and their sequelae can be debilitating. They tend to present with severe infections but minimal symptoms probably due to neuropathy and vasculopathy among diabetics. The study aims to compare the demographic characteristics, clinical presentations and outcomes of upper limb infections between diabetic and non-diabetic patients.

METHODS

All patients with upper limb infections who were admitted in a tertiary hospital from June 2017 to December 2020 were included in this study. Demographic data, clinical presentations, investigations and outcomes were obtained retrospectively from electronic medical record. There were 117 patients with diabetes mellitus and 127 with no diabetes mellitus. Comparisons were made between these two groups, and statistical analysis was done with SPSS.

RESULTS

There were 244 patients included; 117 were diabetic and 127 were non-diabetic. Diabetic patients were more likely to present with emergent scenarios, especially necrotizing fasciitis and infective tenosynovitis (p < .05) with higher erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) readings (p < .05). Their microbiological cultures were less likely to be negative (p < .05). Diabetic patients also had poorer clinical outcomes with higher risk of amputation, re-operation and longer duration of hospital stay (p < .05).

CONCLUSION

Upper limb infections among diabetic patients should be treated aggressively. Early diagnosis and surgical intervention might decrease the morbidity and mortality in this group. Prevention of infections should be emphasized.

A1 Pulley Tenderness as a Modification to Tenderness along the Flexor Sheath in Diagnosing Pyogenic Flexor Tenosynovitis

Background:

Pyogenic flexor tenosynovitis (PFT) is frequently diagnosed by physical examination according to the Kanavel signs. This study proposes a modification of the Kanavel sign “tenderness over the course of the flexor sheath” by including palpation of the A1 pulley to increase specificity for diagnosis.

Methods:

A retrospective review was performed over 8 months for patients in the emergency department who received a consult to hand surgery to rule out PFT. Two cohorts, nonPFT infections and PFT infections, were studied for the presence or absence of the four Kanavel signs, as well as tenderness specifically over the A1 pulley on the affected digit(s) or T1 pulley of the thumb.

Results:

There were a total of 33 patients in the two cohorts (21 nonPFT, 12 PFT) with statistically significant differences with regard to the presence of all the Kanavel signs. A1 pulley tenderness had the greatest odds ratio, positive predictive value, specificity, and accuracy when compared with all Kanavel signs. When used in conjunction with each Kanavel sign, there was an increase in specificity in all four signs. Receiver operating characteristic analysis revealed increased area under the curve with A1 pulley tenderness added, indicating improved ability to classify hand infections as PFT versus nonPFT.

Conclusion:

Although the classic Kanavel signs have shown reliable clinical utility, this study finds that tenderness at the A1 pulley can be a useful specification of “tenderness over the course of the flexor sheath” to help with the diagnosis of PFT.

Pyogenic Extensor Tenosynovitis of the Wrist-A Cause of Spontaneous Extensor Tendon Rupture: A Report of 2 Cases

CASES

We present 2 cases of spontaneous extensor tendon rupture in the setting of pyogenic extensor tenosynovitis of the wrist caused by penetrating wounds-a cat bite and injection drug use in patients 1 and 2, respectively. Patient 1 underwent reconstruction of the extensor digitorum communis tendons with palmaris longus autograft. Patient 2 declined surgical reconstruction.

CONCLUSIONS

These cases highlight a rare but severe complication of dorsal hand/wrist infection. Early surgical intervention should be considered to prevent this complication, which may have permanent functional consequences and requires complex reconstructive and rehabilitative efforts.

Advanced finger infection: more frequent than expected and mostly iatrogenic

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.

Increasing Multidrug Antibiotic Resistance in MRSA Infections of the Hand: A 10-Year Analysis of Risk Factors

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is the most common pathogen isolated from hand abscesses. The purpose of this study was to understand trends and changes in longitudinal antibiotic resistance profiles and risk factors for these infections to better guide empiric treatment of hand infections. Methods: We performed a retrospective review of culture-positive hand infections over a 10-year period at an urban academic institution from 2005 to 2014. A subset of MRSA hand infections from 2013 to 2014 was then subanalyzed for risk factors for antibiotic resistance for antibiotics with increasing antibiotic resistance during this period. Results: MRSA grew in 46% of hand infections, with a decreasing incidence over the 10-year study period. However, in the same time period clindamycin and levofloxacin resistance increased from 7% to 31% and 12% to 56%, respectively. Risk factors for clindamycin resistance included nosocomial infections and a history of intravenous drug use and hepatitis C. Risk factors for levofloxacin resistance included a history of diabetes and a fever upon initial presentation. Conclusions: The incidence of multidrug resistance remains high, with growing resistance to clindamycin and levofloxacin. There remains a trend for increased clindamycin resistance for patients with history of intravenous drug use and nosocomial infections. Our findings indicate that clindamycin and levofloxacin should be avoided for empiric treatment for hand infections in patients with these risk factors.

Initial Debridement of Dorsal Hand Abscesses in the Operating Room Does Not Improve Outcomes

Background: Hand infections frequently involve the dorsal aspect of the hand and often develop secondary to some traumatic mechanism. Although Staphylococcus aureus is most commonly isolated, anaerobic and polymicrobial infections are not uncommon. To date, treatment is largely anecdotal, with some surgeons preferring a formal debridement in the operating room, while others opt for an initial debridement at the bedside. The goals of this study were to compare outcomes between treatment modalities and to identify the most common causative organisms. Methods: A 10-year retrospective chart review was conducted to identify adult patients who presented with a dorsal hand infection to a single, level 1, urban trauma center. Demographic data were collected as well as the abscess size, location, duration of symptoms, treatment administered, number of formal debridements, length of hospital stay, and complications. Results: The number of formal debridements was significantly less in the initial bedside debridement group (P < .01), as was the hospital length of stay (P < .01). There was no significant difference in hospital readmissions, complications, or infection due to methicillin-resistant Staphylococcus aureus. There was also no significant difference in abscess size, duration of symptoms, or demographic data including age, sex, comorbidities, intravenous drug use status, and immunocompromised status. Conclusions: An initial debridement of dorsal hand infections at the bedside is at least as effective as formal debridement in the operating room. This decreases number of formal debridements and days in the hospital, without any increase in complications. This permits safe, expeditious, and cost-effective treatment for this common condition.

Pyogenic Flexor Tenosynovitis: Evaluation and Management

Pyogenic flexor tenosynovitis is a closed-space infection that can lead to a devastating loss of finger and hand function. It can spread rapidly into the palm, distal forearm, other digits, and nearby joints. Healthy individuals may present with no signs of systemic illness and often deny any penetrating trauma or inoculation. Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function. Many treatment options have been described, although all share 2 common principles: evacuation of the infection and tailored postoperative antibiotic treatment with close monitoring to ensure clinical improvement.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT) is a common closed-space infection of the flexor tendon sheaths of the hand, which remains one of the most challenging problems facing hand surgeons. PFT goes by several names including septic or suppurative flexor tenosynovitis. Adequate treatment requires timely diagnosis and often prompt surgical treatment. However, despite prompt treatment, and regardless of the protocol used, complication rates as high as 38% have been reported in the literature. Moreover, even with successful eradication of the infection, a significant proportion of patients will suffer from continuing pain, swelling, stiffness, loss of composite flexion, weakness, and recurrence potentially requiring amputation. This review will focus on current evidence-based antimicrobial and surgical treatment strategies to maximize treatment outcomes.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT)is a potentially devastating closed-space infection of the flexor tendon sheath of the hand that can result in considerable morbidity. Management of PFT, regardless of the pathogen, includes prompt administration of empirical intravenous antibiotics and often surgical treatment. However, currently, there is no standardized treatment algorithm for PFT in regards to the need for, timing, or type of surgical treatment. Many utilize a combination of surgical decompression and sheath irrigation. However, despite prompt treatment, and regardless of the protocol used, complication rates can be high, leading to impaired function and even amputation of the affected digit. Further research is needed to elucidate the role of local antibiotics and corticosteroids in treating this condition and potentially preventing the morbid outcomes that are currently seen. This paper reviews the background, microbiology, and treatment options and controversies surrounding PFT.

Susceptibility of microorganisms causing acute hand infections

Hand infections are a common presentation at the emergency departments. Without knowing the source of infection clinicians are dependent on systematic reports on the bacterial spectrum and susceptibility tests of the specific infection in their patient community. This study was based on a retrospective chart review of patients presenting to our outpatient clinic with acute hand infections. We documented patient demographics, the etiology, location, culture tests of the infection and analyzed if certain bacteria could be cultured significantly more often in certain etiologies or in specific sites of the hand infection. Susceptibility tests were added. Bacterial swabs of 204 patients were analyzed. Overall S. aureus was found in 53% of all cases, in only one case revealed methicillin-resistant S. aureus (MRSA). There was no significant difference in the bacterial spectrum according to the etiology of the hand infections, except for animal bites where Pasteurella multocida was the dominating bacteria in 63% of all cases. Amoxicillin-clavulanic acid, fluoroquinolones, and piperacillin were effective against the main bacteria. Our study confirms the previously published antibiotic resistance reports and reinforces the current antibiotic treatment guidelines also in this western European population.

Ultrasound for the diagnosis of pyogenic flexor tenosynovitis

The usefulness of ultrasound for making the diagnosis of pyogenic flexor tenosynovitis (PFTS) has been demonstrated. The primary goal of this study was to show that the diameter of the flexor sheath near the A2 pulley was larger when PFTS was present compared to the healthy contralateral finger. The secondary goal was to determine the reproducibility of these ultrasound measurements. Our series included 20 patients (12 men and 8 women) operated due to PFTS. The average age was 41.7 years old. The average diameter of the digital sheath measured near the A2 pulley on transverse and longitudinal ultrasound sections was 5.01mm (transverse 5mm, longitudinal 5.03mm) on infected fingers, and 4.17mm on healthy contralateral fingers. Reproducibility, as measured by the intraclass coefficient between transverse and longitudinal values, was 0.910 for infected fingers and 0.928 for contralateral fingers, thus was excellent. Our hypothesis was confirmed. A unilateral increase of more than 20% in diameter of the flexor sheath measured in transverse or longitudinal ultrasound sections near the pulley A2 contributes to the surgical indication when a patient presents with PFTS.

Quantifying the Effect of Diabetes on Surgical Hand and Forearm Infections

PURPOSE

Diabetes has long been established as a risk factor for hand and forearm infections. The purpose of this study was to review the effect of glycemic factors on outcomes among diabetic patients with surgical upper-extremity infections. We hypothesized that diabetic inpatients may benefit from stronger peri-infection glycemic control.

METHODS

A prospective cohort study enrolled diabetic and nondiabetic surgical hand and forearm infections over 3 years. Glycemic factors included baseline glycosylated hemoglobin, blood glucose (BG) at presentation, and inpatient BG. Poor baseline control was defined as glycosylated hemoglobin of 9.0% or greater and poor inpatient control as average BG of 180 mg/dL or greater. The main outcome of interest was the need for repeat therapeutic drainage. Multivariable logistic regression quantified the association between diabetic factors and this outcome.

RESULTS

The study involved 322 patients: 76 diabetic and 246 nondiabetic. Diabetic infections were more likely than nondiabetic infections to result from idiopathic mechanisms, occur in the forearm, and present as osteomyelitis, septic arthritis, and necrotizing fasciitis. Diabetic microbiology was more likely polymicrobial and fungal. After first drainage, diabetic patients were more likely to require repeat drainage and undergo eventual amputation. Among diabetic patients, poor inpatient control was associated with need for repeat drainage.

CONCLUSIONS

Diabetes exacerbates the burden of surgical upper-extremity infections: specifically, more proximal locations, deeper involved anatomy at presentation, broader pathogenic microbiology, increased need for repeat drainage, and higher risk for amputation. Among diabetic patients, poor inpatient glycemic control is associated with increased need for repeat drainage.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Differentiation Between Pyogenic Flexor Tenosynovitis and Other Finger Infections

BACKGROUND

Hospital transfer decisions regarding pyogenic flexor tenosynovitis (PFT) are made difficult by emergency department presentations similar to other finger infections, with pain, redness, and functional limitation. Our objectives were to: (1) determine diagnostic sensitivity and specificity of Kanavel signs; and (2) identify existing factors most predictive of PFT during initial presentation.

METHODS

Adult patients who underwent surgical consultation for concern of PFT over a 5-year period were identified retrospectively. Bivariate screening identified clinical criteria for differentiation, and multivariate logistic regression was performed to control for confounding. We then created a prediction algorithm for diagnosis of PFT. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy.

RESULTS

Patients with PFT differed significantly from those with non-PFT finger infections in regard to the 4 Kanavel signs, duration of symptoms less than 5 days, and erythrocyte sedimentation rate. Sensitivity of the Kanavel signs ranged from 91.4% to 97.1%. Specificity ranged from 51.3% to 69.2%. Logistic regression identified independent predictors for PFT as tenderness along the flexor tendon sheath, pain with passive extension, and duration of symptoms less than 5 days. A prediction algorithm incorporating these 3 factors showed an area under the ROC curve of 0.91 (95% confidence interval, 0.840-0.979).

CONCLUSIONS

Kanavel signs have high sensitivity for detecting PFT but have poor specificity on an individual basis. Clinical prediction algorithms that combine the relevant factors may be helpful in the development of clinical prediction tools and educational materials for optimization of emergency hand care systems. Further prospective study is needed.

Prospective Randomized Trial Comparing the Efficacy of Surgical Preparation Solutions in Hand Surgery

BACKGROUND

Decontamination of the skin prior to incision is part of the standard of care for any surgical procedure. Previous studies have demonstrated variable efficacy of different surgical preparation solutions based on anatomic location. The purpose of this study is to determine the effectiveness of 3 commonly used surgical preparation solutions in eliminating bacteria from the skin prior to incision for common elective soft tissue hand procedures.

METHODS

A total of 240 patients undergoing clean, elective, soft tissue hand surgery were prospectively randomized to 1 of 3 groups (ChloraPrep, DuraPrep, or Betadine). Prepreparation and postpreparation cultures were obtained adjacent to the surgical incision and neutralization was performed on the obtained specimen. Cultures were held for 14 days and patients followed for 6 weeks postoperatively.

RESULTS

Postpreparation cultures were positive in 21 of 80 (26.3%) ChloraPrep patients, 3 of 79 (3.8%) DuraPrep patients, and 1 of 81 (1.2%) Betadine patients ( P < .001). There was no difference in the postpreparation culture rate between DuraPrep and Betadine ( P = 1.000).

CONCLUSIONS

Duraprep and Betadine were found to be superior to Chloraprep for skin decontamination prior to clean elective soft tissue hand surgery. The bacterial flora of the hand was found to be different from those of the shoulder and spine. The clinical significance of this finding requires clinical consideration because the majority of prepreparation and postpreparation positive cultures were of Bacillus species, which are rarely a cause of postoperative infections.

Flexor Tenosynovitis

For patients with suspected flexor tenosynovitis, the mainstay of diagnosis is a thorough history and physical examination. The examination is guided by evaluating the patient for Kanavel's four cardinal signs. Empiric antibiotics should be started immediately on diagnosis covering skin flora and gram-negative bacteria. Typically, surgery is required. Appropriate exposure is required for adequate treatment and incisions should be tailored to preserve areas of skin compromised from draining sinuses and abscess pressure. Diabetes mellitus and peripheral vascular disease place patients at higher risk of poor outcomes including stiffness and amputation; early administration of antibiotics is the intervention that correlates most closely with good outcomes.

MDCT of hand and wrist infections: emphasis on compartmental anatomy

Hand and wrist infections can present with a spectrum of manifestations ranging from cellulitis to deep-space collections. The various infectious processes can be categorised as superficial or deep infections based on their respective locations relative to the tendons. Superficial hand infections are located superficial to the tendons and are comprised of cellulitis, lymphangitis, paronychia, pulp-space infections, herpetic whitlow, and include volar as well as dorsal subcutaneous abscesses. Deep hand infections are located deep to the tendon sheaths and include synovial space infections, such as infectious tenosynovitis, deep fascial space infections, septic arthritis, necrotising fasciitis, and osteomyelitis. Knowledge of hand and wrist compartmental anatomy is essential for the accurate diagnosis and management of hand infections. Although early and superficial infections of the hand may respond to non-surgical management, most hand infections are surgical emergencies. Multidetector computed tomography (MDCT), with its muliplanar reformation (MPR) and three-dimensional (3D) capabilities, is a powerful tool in the emergency setting for the evaluation of acute hand and wrist pathology. The clinical and imaging features of hand and wrist infections as evident on MDCT will be reviewed with emphasis on contiguous and closed synovial and deep fascial spaces. Knowledge of hand compartmental anatomy enables accurate characterisation of the infectious process and localise the extent of disease in the acute setting.

Predicting serious complications and high cost of treatment of tooth-knuckle injuries: a systematic literature review

PURPOSE

The tooth-knuckle injury (TKI) is a serious and potentially costly injury seen in orthopaedic practice. The aim was to conduct a systematic literature review on the factors associated with serious complications and high treatment costs in tooth-knuckle injuries.

METHODS

MEDLINE, Scopus and CINAHL were used as the literature sources.

INCLUSION CRITERIA

Original research papers that reported on factors predicting serious complications and high treatment costs in TKIs were included. There were no restrictions placed on study size, language, study design or date of publication.

EXCLUSION CRITERIA

Case studies, case series and review articles were not included.

RESULTS

After duplicates were removed, 403 unique studies remained; after titles and abstracts were screened, 48 titles remained and were retrieved in full text. Of these, 14 titles met the inclusion criteria and were included in the data synthesis. Tenosynovitis, septic arthritis, osteomyelitis and residual stiffness were common serious complications occurring in up to 36.3, 70.0, 47.6 and 65.3 % of cases, respectively. Amputation was also common in up to 18.0 % of injuries. Treatment costs were measured by length of hospital stay and the number of debridements required. On average, patients required 3.8-8 days of admission and 1.3-2.7 debridements each.

CONCLUSION

Increased time delay from injury to treatment, deeply penetrating injuries, proximal interphalangeal joint (PIPJ) injuries and, possibly, E. corrodens infections were associated with serious complications in TKIs. Delayed treatment, inadequate treatment, PIPJ injuries and deeply penetrating injuries predicted higher treatment costs.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42016029949 ( http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016029949 ).

The Effects of Early Antibiotic Administration on Bacterial Culture Growth From Hand Abscesses

BACKGROUND

Traditional management of hand abscesses consists of withholding antibiotics prior to drainage to optimize bacterial culture growth and outcome. The purpose of this study was to determine the effect of preoperative empiric antibiotics on the rate of culture growth and rate of adverse events in patients with acute hand abscesses.

METHODS

We performed a retrospective review of prospectively collected data on 88 consecutive hand abscesses that received empiric antibiotics prior to incision and drainage from 2012 to 2013 at an urban academic institution. We analyzed patient demographics, bacteriology, culture growth results, time to surgery, and frequency of adverse events.

RESULTS

The overall rate of positive culture growth was 90% (n = 79) despite running the antibiotics for a mean of 31 hours prior to debridement. Furthermore, 96% of the isolates were given a susceptible antibiotic during that time. The mean number of debridements was 1.5 per patient, but 4 re-operations were necessary for wound complications. No patients required an amputation or were upgraded to intensive care.

CONCLUSIONS

Preoperative empiric antibiotic administration does not appear to greatly reduce bacterial culture growth from hand abscesses. The adverse events are relatively few for simple abscesses treated with pre-surgical antibiotics and decompression within 24 hours.

A systematic review of the management of acute pyogenic flexor tenosynovitis

Pyogenic flexor tenosynovitis (PFT) is an aggressive closed-space infection that can result in severe morbidity. Although surgical treatment of pyogenic flexor tenosynovitis has been widely described, the role of antibiotic therapy is inadequately understood. We conducted a literature review of studies reporting on acute pyogenic flexor tenosynovitis management. A total of 28 case series articles were obtained, all of which used surgical intervention with varied use of antibiotics. Inconsistencies among the studies limited summative statistical analysis. Our results showed that use of antibiotics as a component of therapy resulted in improved range of motion outcomes (54% excellent vs. 14% excellent), as did using catheter irrigation rather than open washout (71% excellent vs. 26% excellent). These studies showed benefits of early treatment of pyogenic flexor tenosynovitis and of systemic antibiotic use. As broad-spectrum antibiotics have changed the management of other infectious conditions, we must more closely evaluate consistent antibiotic use in pyogenic flexor tenosynovitis management.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Hand infections: a retrospective analysis

Purpose. Hand infections are common, usually resulting from an untreated injury. In this retrospective study, we report on hand infection cases needing surgical drainage in order to assess patient demographics, causation of infection, clinical course, and clinical management. Methods. Medical records of patients presenting with hand infections, excluding post-surgical infections, treated with incision and debridement over a one-year period were reviewed. Patient demographics; past medical history; infection site(s) and causation; intervals between onset of infection, hospital admission, surgical intervention and days of hospitalization; gram stains and cultures; choice of antibiotics; complications; and outcomes were reviewed. Results. Most infections were caused by laceration and the most common site of infection was the palm or dorsum of the hand. Mean length of hospitalization was 6 days. Methicillin-resistant Staphylococcus aureus, beta-hemolytic Streptococcus and methicillin-susceptible Staphylococcus aureus were the most commonly cultured microorganisms. Cephalosporins, clindamycin, amoxicillin/clavulanate, penicillin, vancomycin, and trimethoprim/sulfamethoxazole were major antibiotic choices. Amputations and contracture were the primary complications. Conclusions. Surgery along with medical management were key to treatment and most soft tissue infections resolved without further complications. With prompt and appropriate care, most hand infection patients can achieve full resolution of their infection.

Hand infections

Many acute hand and upper extremity infections should be treated as surgical emergencies to avoid stiffness, contracture, pain, and amputation. Proper treatment requires understanding of anatomy and how this influences the behavior of certain infections, common offending organisms, antibiotic treatment, management of host factors, and surgical intervention. This article reviews the microbiology, antibiotic coverage, and surgical treatment of the most common infections in the hand: paronychia, felon, herpetic whitlow, flexor tenosynovitis, deep space infections, septic arthritis, bites from humans and animals, necrotizing fasciitis, mycobacterium infections, and fungal infections. Recommendations are based on the most recent available evidence.

Epidemiology of adult acute hand infections at an urban medical center

PURPOSE

To define the current epidemiology of adult acute hand infections in an urban setting, with the aim of helping to improve empiric treatment, as hand infections represent a major source of morbidity and can result in stiffness and, possibly, amputation.

METHODS

We performed an electronic medical record search to identify all patients admitted to our urban academic medical center with diagnoses related to open wounds and infections in the hand and fingers over a 6-year period (2005-2010). We recorded demographic data, location of infection, medical comorbidities, and culture data.

RESULTS

Of the 2,287 patients admitted with diagnoses related to open wounds and infections in the hand and fingers, 1,507 incision and drainage procedures were performed, which resulted in 458 patients (30%) with culture-positive infections. Wound cultures identified 39 different species of bacteria. Most of these were methicillin-resistant Staphylococcus aureus, which compromised 53% of positive cultures, followed by methicillin-sensitive S aureus in 23% of positive cultures. The cultures were polymicrobial in 19%. History of intravenous drug use or diabetes mellitus was a strong predictor of polymicrobial infection.

CONCLUSIONS

Methicillin-resistant Staphylococcus aureus was the most common bacteria cultured from these infections. Empiric antibiotic coverage should routinely cover methicillin-resistant S aureus. We noted a higher incidence of polymicrobial infections than previously reported, particularly with intravenous drug use, diabetes, and human bites. Volar hand infections had the highest percentage of positive cultures, whereas paronychia had the lowest percentage.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Evolving incidence of MRSA in urban hand infections

Methicillin-resistant Staphylococcus aureus (MRSA) is the most commonly cultured bacteria in hand infections. Understanding the most common bacteria involved in hand infections allows appropriate and efficient administration of antibiotics. Delay in treatment may lead to increased morbidity, including stiffness, contracture, and amputation. The purposes of this study are to determine whether the incidence of MRSA in culture-positive hand infections continues to increase and whether MRSA is a risk factor for increased length of stay. Electronic medical records were queried to identify patients admitted to a large, academic urban medical center with the diagnosis of a hand infection between January 1, 2005, and December 31, 2009. Methicillin-resistant S aureus accounted for 220 of the positive cultures over the 5-year study period. Polymicrobial infection represented 81 positive cultures, and MRSA was only present in 10 of these cases. Patients with MRSA were found to have a mean length of hospital stay of 4.1 days compared with 4.5 days in non-MRSA infections. Understanding the most common bacteria involved in hand infections allows appropriate and efficient administration of antibiotics. Methicillin-resistant S aureus is the most commonly cultured bacteria in the hand. However, polymicrobial infections have become increasingly more common. Although incidences of polymicrobial infections increased over the study period in this series, clinical judgment should be exercised before initiating broad-spectrum antibiotic coverage.

HAND INFECTION IN DIABETIC PATIENTS

The diabetic hand infection is less reported in the literature. Therefore, it is easily ignored and underestimated resulting in increased morbidity among the diabetic population. Diabetic hand is a rapid in progression, extensive and severe tissue destruction. We analyze the clinical course and outcome of hand infection in diabetic patients. We reviewed all the admissions with hand infection from January 2006–April 2010. Thirty-seven patients were found with associated diabetes mellitus. The demographic data, culture report, number of operations and management, hospital stay and outcome-like amputation were recorded. The average age was 62 years. Pain and swelling were the chief complaints. The cause of infection was varied. The infection was superficial in 13 and deep in 24 patients. Forty-one percent of culture report revealed polymicrobial organism. The increased length of hospital stay, reoperations and amputation were associated with deep infection and polymicrobial organism.

Prompt medical and surgical attentions are the most important factors. A proper glycemic control, elevation of the affected extremity, thorough and adequate surgical debridement and appropriate antibiotics are the important considerations when dealing with diabetic hand infection.

Postoperative infections: prevention and management

Postoperative infections continue to be a challenging problem. The incidence of bacterial antibiotic resistance such as methicillin-resistant Staphylococcus aureus is rising. There are numerous intrinsic patient factors that should be optimized before surgery to minimize the risk of surgical site infections. When postoperative infections develop, treatment must be individualized. This article outlines the principles that can help guide treatment.

Complications after flexor tendon injuries

Management of flexor tendon injuries is one of the most demanding tasks in hand surgery. Despite substantial improvements in surgical technique and postoperative rehabilitation protocols, functional outcomes may still be somewhat unreliable. In the present article, the authors present complications encountered after flexor tendon repair and provide their preferred methods of prevention and treatment.

Hand infections

Hand infections are very common and must be properly diagnosed and treated to minimize the potentially devastating functional complications. Acute hand infections include felon, paronychia, deep-space infections, septic arthritis, osteomyelitis, and necrotizing fasciitis. Chronic infections are usually caused by atypical mycobacteria and fungi. There are several conditions that mimic acute hand infections, and it is important to recognize them so that the appropriate treatment can be instilled. To prevent all these complications and poor outcome, prompt diagnosis and early institution of appropriate surgical management and antibiotic treatment are crucial.

Hand Trauma Pitfalls: A Retrospective Study of Fight Bites

Clench fist or fight bite injuries are associated with some of the worst types of infective complications but their mechanism is often poorly understood. In a retrospective case series, 34 patients seen between 1998 and 2004 presented to a local hand surgery unit with confirmed human bite hand injuries. Seventy-six percent presented with infective complications with a mean delay in presentation of 4 days. Eighty percent of patients were clench fist injuries (CFI) (open joints in 59% and tendon injuries in 63%). Using an aggressive treatment policy including early surgical and antibiotic intervention, most patients achieved good results functionally (full range of movement was achieved in 83% of those with CFI which completed follow-up (44%)). High rates of non-compliance and incomplete follow-up was noted. Major long-term complications including limited range of movement and osteomyelitis was low and suggests the policy of prompt and comprehensive surgical and medical intervention is the optimal treatment option. A brief but in-depth discussion of the specific anatomical pitfalls is included.

Factors affecting the prognosis of pyogenic flexor tenosynovitis

BACKGROUND

Pyogenic flexor tenosynovitis is a closed space infection involving the digital flexor tendon sheaths of the upper extremity that can cause considerable morbidity. The purpose of the present report is to describe the various risk factors leading to poor outcomes and to recommend a clinical classification system for this condition.

METHODS

We studied seventy-five patients with pyogenic flexor tenosynovitis over a six-year period. The amputation rate and total active motion were used as outcomes measures. The clinical factors influencing outcomes were identified and analyzed.

RESULTS

The five risk factors associated with poor outcomes were (1) an age of more than forty-three years, (2) the presence of diabetes mellitus, peripheral vascular disease, or renal failure, (3) the presence of subcutaneous purulence, (4) digital ischemia, and (5) polymicrobial infection. On the basis of the clinical findings and outcomes, three distinct groups of patients could be identified, each with a progressively worse outcome. Patients in Group I had no subcutaneous purulence or digital ischemia; these patients had the best prognosis, with no amputations and a mean 80% return of total active motion. Patients in Group II demonstrated the presence of subcutaneous purulence but no ischemic changes; these patients had an amputation rate of 8% and a mean 72% recovery of total active motion. Patients in Group III had both extensive subcutaneous purulence and ischemic changes; these patients had the worst prognosis, with an amputation rate of 59% and a mean 49% return of total active motion.

CONCLUSIONS

We propose a three-tier clinical classification system that can aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis of the upper extremity.

Community-associated methicillin-resistant Staphylococcus aureus hand infections in an urban setting

PURPOSE

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection appears to be increasing. The purpose of this study was to determine prospectively the incidence of MRSA in community-associated hand infections in an urban hospital.

METHODS

Sixty-one patients presented to our institution over a 9-month period with community-acquired hand infections that were evaluated and treated by the hand service. The specimens obtained during the initial evaluation and treatment were cultured and subjected to antibiotic susceptibility testing. Four nosocomial infections and 5 fight bites were excluded.

RESULTS

Of the remaining 52 patients, 38 (73.1%) were MRSA positive.

CONCLUSIONS

The rate of community-associated MRSA hand infections in an urban setting is higher than previously suspected. This should be taken into account when managing seemingly routine hand infections given that the treatment options are different for MRSA infections.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Epidemiology of bacterial hand infections

OBJECTIVE

The aim of the study was to delineate and update the bacteriological spectrum, characterize patterns and sites of injury, evaluate laboratory tests and possible causes of complications in patients with bacterial hand infections.

METHODS

All hand infections operated on in the department of orthopedics at Odense University Hospital during the period 1992-2001 were reviewed retrospectively. A standard protocol was used to collect data for each patient. We also examined all laboratory reports and recorded the identity of the etiologic organism, if known, for all cases of bacterial hand infections.

RESULTS

Four hundred and eighteen patients (296 men and 122 women) with hand infections were operated on between 1992 and 2001 in our department. The median age of the patients was 40 years (range 1-93). The average interval from primary injury to operation was 10 days (range 1-50). The etiology was laceration/puncture in 35%. The site of infection was subcutaneous in 45% followed by tendon, joint and bone in 27, 18 and 5%, respectively. The bacteria isolated from the patients showed that 184 cultures (44%) were pure Staphylococcus aureus followed by 49 cultures (11.7%) of mixed organisms. Body temperature and C-reactive protein (CRP) were normal in three quarters of all patients with hand infections in our series. However the erythrocyte sedimentation rate (ESR) was elevated in 50% of the patients and was a significantly better test for infection in this study than CRP (p = 0.002). Neither the severity of infection nor the etiology of infection was related in any way to the initial temperature, CRP or ESR in this study. Complications were noted in 14.8% of all patients, and were especially related to diabetes, and mixed infection.

CONCLUSION

Despite modern antibiotics, hand infections with a variety of organisms continue to be a source of morbidity and possible long-term disability. Most hand infections are the result of minor wounds that have been neglected. A complete history and physical examination is necessary to exclude other associated medical conditions (diabetes, arthritis, immunosuppression) that may compromise therapy. Furthermore, our study confirms that Staphylococcus aureus is responsible for most instances of hand infection, followed by mixed organisms. Gram-negative organisms are frequently cultured in patients with diabetes and intravenous drug abuse.

Infections of the upper extremity in hospitalized diabetic patients: A prospective study

OBJECTIVES

To study the clinical characteristics of a group of patients with diabetes and established upper extremity infections and to determine the causative factors of hand infections.

METHODS

Prospective study of diabetic patients referred in to our service with infections of the upper extremity from January 1992 to December 2001.

RESULTS

Twenty-six diabetic patients with an infection of the upper extremity were studied (17 F, 9 M). The admission rate equalled 0.7%. Twenty-one patients (80.8%) presented a Type 2 diabetes and 5 a Type 1 diabetes (19.2%). The diagnosis age of diabetes was 44.6 +/- 13.8 Years (range: 16-62). The average age at the occurrence of the lesion was 52.5 +/- 15.1 Years (range: 21-73). The average duration of diabetes was 8.3 +/- 5.9 Years (range: 0-22). Diabetes was, in all the cases, poorly controlled because of an inadequate hypoglycaemic treatment and/or bad compliance. The patients had a high prevalence of peripheral neuropathy (n=17; 65.4%). The delays in presentation to the doctor and those related to hospitalization were respectively 9.1 +/- 10.0 days (n=23) and 16.8 +/- 12.1 days. The hospitalization length reached 33.6 +/- 22.6 days (range: 7-93). The final results, 6 Months after hospitalization, were as follows: the death rate reached 19.2% (n=5); 23.1% of the patients (n=6) had a minor amputation; for 53.8% of the patients (n=14), the lesions healed without any amputation. One patient left hospital against medical advice. Eleven out of 20 patients (55%), amputated or not, were left with deformities and a subjective dysfunction of the affected limb.

CONCLUSION

Infections of the upper extremity in diabetic patients constitute an uncommon but serious complication. They seem to be more frequent in housewives. They result in a high morbIdity. Prevention of these infections should be based on patients' education (compliance with diabetes treatment, hand care, prompt visit to the doctor) and General Practitioners' training for an adequate treatment and/or a rapId patient referral to hospital.

Closed-catheter irrigation is as effective as open drainage for treatment of pyogenic flexor tenosynovitis

Surgical treatment of pyogenic flexor tenosynovitis traditionally consists of open drainage (OD) and irrigation of the flexor tendon sheath. An alternative, less traumatic method of closed-catheter irrigation (CCI) has been advocated, but no comparative studies have been reported. The authors reviewed 47 cases of pyogenic flexor tenosynovitis to determine whether a difference in outcomes exists between these two methods. OD was used in 32 patients and CCI was used in 15 patients. Complications appeared to be more common in the OD group (N = 9) compared with the CCI group (N = 3), but this difference was not significant. This study supports the use of CCI as the preferred treatment for pyogenic flexor tenosynovitis because it provides thorough mechanical tendon sheath irrigation and causes smaller wounds with less scarring, which may offer a more rapid return to function.