Closed-space hand infections: diagnostic and treatment considerations

Septic arthritis of the wrist: A case of Parona space abscess in a rheumatoid arthritis patient with Charcot wrist

Closed-space hand infections are considered an emergency requiring prompt management to avoid debilitating consequences and potential morbidity. Septic arthritis of the wrist is particularly uncommon in comparison to the large joints that are usually affected. We report a case of a 64-year-old female with known rheumatoid arthritis and neuropathic wrist, with superimposed septic arthritis of the wrist, complicated by abscess formation. Ultrasound and Magnetic resonance imaging revealed spread of infection to the midpalmar region and the space of Parona. Although collections in this space are extremely rare, if left untreated, they may lead to permanent disability. Incision and drainage of the abscess along with synovectomy of the affected wrist joint was performed. Streptococcus pneumoniae was the causative organism, despite the fact that Non-gonococcal and Staphylococcus aureus bacteria are the main causative agents of septic arthritis in adults.

Upper extremity infection: imaging features with focus on magnetic resonance imaging

Upper extremity infections are frequently seen, especially in individuals with weakened immune system, posttraumatic events, and after surgery procedures. If not properly treated, such conditions can lead to serious consequences, such as movement impairment, amputation, and even mortality. These infections have the potential to spread extensively from their initial site of entry, traversing interconnected spaces either intra or extra-compartmental. Understanding the relevant anatomy is crucial to assess location and stage of infection, since surgical intervention and intravenous antibiotics are usually required. In this article, the authors provide a comprehensive review of the imaging findings of upper extremity infection, focusing on magnetic resonance imaging (MRI). Furthermore, this article sheds light on the pivotal role of radiology in managing hand, elbow, and shoulder infections offering an overview of available treatment options. KEY FINDINGS: Various types of infections affecting the upper extremity will be discussed, including infectious tenosynovitis, deep space infections, septic arthritis, and osteomyelitis. Authors also highlight anatomical spaces, common pathogens, spread routes, and key radiological features of these conditions.

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).

Collar-button abscess as a complication of infected hematoma in the setting of uncontrolled type 2 diabetes

INTRODUCTION

Collar-button abscesses are deep space infections of the hand.

CASE PRESENTATION

We present a case of a 66-year-old man who developed an acute collar-button abscess of the hand after a concrete bench fell onto the dorsal aspect of his hand. The hand abscess was managed successfully with intravenous antibiotics and operative intervention.

DISCUSSION

While such infections comprise a small percentage of hand infections, insufficient or delayed treatment results in permanent hand disfiguration and dysfunction. This case highlights an uncommon dorsal-to-volar pattern of hand abscess extension.

CONCLUSION

Knowledge of the anatomy of the hand is essential to diagnosis and appropriate surgical management.

Acute-Phase Reactants in Operatively Treated Upper Extremity Infections: A Retrospective Review

Background: There are limited data on the use of acute-phase markers in the diagnosis of upper extremity infections. The goal of this study was to determine the percentage of patients with elevated white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) in the setting of an upper extremity infection requiring operative debridement. Methods: In a retrospective review over 12 years, 61 patients who met the inclusion criteria were identified. Results: C-reactive protein was the most sensitive test in the detection of culture-positive infection compared with ESR and WBC (P < .001, P < .0001, respectively). Ninety percent of patients (55 of 61) presented with an abnormal CRP value. The WBC count and ESR were abnormal in 54% and 67% of our cohort, respectively. Conclusions: C-reactive protein is the most sensitive laboratory test when evaluating upper extremity infections that necessitate debridement. The WBC count and ESR should be interpreted with caution and can be normal even in the presence of an infection.

Spread of Hand Infection According to the Site of Entry and Its Impact on Treatment Decisions

Background: Hand infections can spread quickly and destroy functional structures. Early diagnosis and adequate therapy can prevent severe morbidities. The aim of this study was to evaluate systematically the spread of hand infections according to injury mechanism, pathogens, and entry site. Methods: The data and medical records of 425 patients were collected and analyzed retrospectively. Results: The entry site had a significant influence on the severity of hand infections. Especially finger lesions led to severe infections. Furthermore, a high C-reactive protein (CRP) concentration correlated with more involved compartments of the hand. Bacterial counts also correlated with the number of compartments involved. Conclusions: Compared with known factors for the severity of hand infections finger lesions lead to especially severe infections and should not be underestimated. If there is a higher CRP concentration or more than one bacterial species isolated, compartments adjacent to the site of injury should be checked intra-operatively.

Infections of Deep Hand and Wrist Compartments

The human hand is the most exposed part of the body to highest risk for injuries, loss of the skin integrity, and to the inoculation of bacteria, most commonly Staphylococcus aureus, Streptococcus β-haemolytic, and gram-negative. In case of an infection, the mobile anatomical structures and the synovial membranes in close proximity to each other may spread the pus towards deep spaces and compartments. Mild early infections without an abscess formation may respond to antibiotics, but at more advanced stage, erythema, swelling, stiffness, and severe pain may ensue. Abscess formation will cause debilitating pain, fever, systemic symptoms, and even sepsis. Necrotizing infections may threaten not only the limb, but also patient’s life. Therefore, an initially “trivial” hand injury should never be neglected, as it might turn into a deep space infection, which must be treated immediately with drainage, wound debridement, and i.v. antibiotics. Delay in diagnosis and inadequate initial management might rapidly lead to abscess formation, destruction of the gliding surfaces and the normal anatomy, and irreparable functional deterioration.

Horseshoe abscess of the hand with rice bodies secondary to mycobacterium avium intracellulare infection

A horseshoe abscess is caused by infection that spreads between the flexor tendon sheath of the thumb or little finger through the radial and ulnar bursae through communication between the two and/or the space of Parona. We present a case of an 80-year-old woman with rheumatoid arthritis who presented with 6 months of right hand and wrist soft tissue swelling, initially treated as a rheumatoid arthritis flare. MRI demonstrates the horseshoe abscess and after surgical irrigation and debridement with synovectomy, cultures demonstrated infection with mycobacterium avium intracellulare (MAI). This case demonstrates the importance of MRI in diagnosing and evaluating the extent of hand infections and for considering mycobacterial organisms for appropriate treatment and antibiotic regimen.

Flexor Pollicis Longus Tendoscopy

The deep palmar spaces of the hand include the midpalmar space, the hypothenar space, the thenar space, space of Parona, and the interdigital web spaces. There are various communications between different spaces. These communications are of clinical importance in explaining the spread of inflammatory, infectious, and even neoplasic processes that involve this region. Surgical incision and drainage of all potentially communicating spaces and compartments is mandatory in deep hand infections. The purpose of this technical note is to describe the minimally invasive approach of endoscopic drainage and debridement of the flexor pollicis longus tendon sheath, radial bursa, and thenar space.