Compartmental infections of the hand

Surgical Antimicrobial Prophylaxis in Patients of Neonatal and Pediatric Age Undergoing Orthopedic and Hand Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication in any type of surgery and can occur up to one year after the procedure in the case of implant placement. In the field of orthopedic and hand surgery, the rate of SSIs is a relevant issue, considering the need for the placement of synthesis devices and the type of some interventions (e.g., exposed fractures). This work aims to provide guidance on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing orthopedic and hand surgery in order to standardize the management of patients and to reduce, on the one hand, the risk of SSI and, on the other, the development of antimicrobial resistance. The following scenarios were considered: (1) bloodless fracture reduction; (2) reduction of unexposed fracture and grade I and II exposed fracture; (3) reduction of grade III exposed fracture or traumatic amputation; (4) cruel fracture reduction with percutaneous synthesis; (5) non-traumatic amputation; (6) emergency intact skin trauma surgery and elective surgery without synthetic media placement; (7) elective orthopedic surgery with prosthetic and/or synthetic media placement and spinal surgery; (8) clean elective hand surgery with and without bone involvement, without use of synthetic means; (9) surgery of the hand on an elective basis with bone involvement and/or with use of synthetic means. This manuscript has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies and represents, in our opinion, the most complete and up-to-date collection of recommendations regarding the behavior to be adopted in the peri-operative setting in neonatal and pediatric orthopedic and hand surgery. The specific scenarios developed are aimed at guiding the healthcare professional in practice to ensure the better and standardized management of neonatal and pediatric patients, together with an easy consultation.

Relevance of antibiotic prophylaxis in the management of surgical emergency open hand trauma

Surgical site infection after emergency hand surgery can cause considerable morbidity and, in the most severe forms, even toxic shock syndrome. Postoperative antibiotic prophylaxis aims to reduce the number of surgical site infections. However, excessive use of antibiotics induces side-effects for patients and antibiotic resistance for society. Contrary to other orthopedic sites, there is no consensus on postoperative antibiotic prophylaxis in open hand trauma beyond analogic reasoning with no proven scientific validity. Our hypothesis was that absence of postoperative antibiotic prophylaxis after open hand trauma surgery does not affect the rate of surgical site infections. A prospective cohort study included 405 patients, operated on in the emergency hand trauma unit without intra- or post-operative antibiotic prophylaxis. Patients were followed up in consultation at 7, 14 and 30 days. Surgical site infection was defined by need for surgery for detersion and flattening, followed by curative antibiotic therapy. The surgical site infection rate was 2.22%. Four patients were lost to follow-up and counted as surgical site infection as originally planned in the worst-case analysis. There were five surgical revisions followed by antibiotic therapy. These results do not differ from those reported in the literature, and thus confirm our hypothesis that postoperative antibiotic prophylaxis is not indicated in open hand trauma management.

Closed-space hand infections: diagnostic and treatment considerations

Despite modern diagnostic methods, surgical advances and antibiotics evolution, acute closed-space hand infections still remain a therapeutic challenge. The aim of this review is to present its special clinical features and the current therapeutic management based on the infection site, the type of the infecting pathogen and the host-type. Anatomic pathways facilitate the spread of the infection towards spots of decreased resistance. The accumulation of purulent material subsequently raises the pressure within the closed-space, leading to ischemia and necrosis. These infections are usually attributed to gram-positive cocci and clinicians should also consider the local spread of community-acquired methicillin resistant S. aureus and the host's comorbidities (immunosuppression, diabetes) before choosing the appropriate antibiotics. Surgical treatment including drainage and irrigation is imperative. The knowledge of anatomy, closed-space pathophysiology and current updates in microbiology and drainage/irrigation techniques are prerequisites for prompt diagnosis and optimal treatment of acute closed-space hand infections.

Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8,850 cases

PURPOSE

Prophylactic antibiotics have been shown to prevent surgical site infection (SSI) after some gastrointestinal, orthopedic, and plastic surgical procedures, but their efficacy in clean, elective hand surgery is unclear. Our aims were to assess the efficacy of preoperative antibiotics in preventing SSI after clean, elective hand surgery, and to identify potential risk factors for SSI.

METHODS

We queried the database from an outpatient surgical center by Current Procedural Terminology code to identify patients who underwent elective hand surgery. For each medical record, we collected patient demographics and characteristics along with preoperative, intraoperative, and postoperative management details. The primary outcome of this study was SSI, and secondary outcomes were wound dehiscence and suture granuloma.

RESULTS

From October 2000 through October 2008, 8,850 patient records met our inclusion criteria. The overall SSI rate was 0.35%, with an average patient follow-up duration of 79 days. The SSI rates did not significantly differ between patients receiving antibiotics (0.54%; 2,755 patients) and those who did not (0.26%; 6,095 patients). Surgical site infection was associated with smoking status, diabetes mellitus, and longer procedure length irrespective of antibiotic use. Subgroup analysis revealed that prophylactic antibiotics did not prevent SSI in male patients, smokers, or diabetics, or for procedure length less than 30 minutes, 30 to 60 minutes, and greater than 60 minutes.

CONCLUSIONS

Prophylactic antibiotic administration does not reduce the incidence of SSI after clean, elective hand surgery in an outpatient population. Moreover, subgroup analysis revealed that prophylactic antibiotics did not reduce the frequency of SSI among patients who were found to be at higher risk in this study. We identified 3 factors associated with the development of SSI in our study: diabetes mellitus status, procedure length, and smoking status. Given the potential harmful complications associated with antibiotic use and the lack of evidence that prophylactic antibiotics prevent SSIs, we conclude that antibiotics should not be routinely administered to patients who undergo clean, elective hand surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Acute compartment syndrome of the forearm secondary to infection within the space of Parona

The deep midpalmar space of the hand communicates with the space of Parona in the forearm. Infection of these deep spaces can be difficult to diagnose. This article presents the first reported case of acute compartment syndrome of the forearm secondary to infection within the space of Parona. This article discusses the anatomy of the space of Parona, highlighting its communicating spaces and the importance of recognizing a deep-space infection of the hand as a possible cause of compartment syndrome of the forearm. This article also suggests a method of clinical examination to aid in the diagnosis of infection within the space of Parona to allow more specific planning of surgical intervention through early decompressive surgery, with surgical exploration to exclude and drain infection when no other clear cause for the rise in pressure within the osteofascial compartment is apparent.