Surgical infections of the hand and upper extremity: a county hospital experience

Hand Osteomyelitis: A Systematic Review of the Literature and Recommendations for Diagnosis and Management

Hand osteomyelitis is a complex condition to diagnose and treat, with an opportunity to improve care through organization of existing evidence. The literature was systematically searched for series of hand osteomyelitis between 1990 and 2022 for evidence regarding diagnosis and treatment, to formulate recommendations. Twenty-one series reported at least 5 cases of hand osteomyelitis in adults, with a total of 666 cases. Surgical debridement is central to treatment and oral antibiotics are sufficient for individuals without diabetes, renal or vascular disease, after debridement and resolution of associated sepsis. A 4- to 6-week duration of antibiotic therapy according to organism sensitivities is recommended, or a 2-week course after amputation. Delayed presentation is common and if over 6 months is associated with high amputation rates. Hand osteomyelitis with renal failure is associated with systemic complications. Reconstruction options include antibiotic-eluting spacers, osteosynthesis or arthrodesis, vascularized bone or adipose, regional soft tissue coverage and silicone implant arthroplasty.Level of Evidence: IV.

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.

Delayed debridement affects prognosis in patients with purulent flexor tenosynovitis: a retrospective cohort and multivariate analyses

INTRODUCTION

Purulent flexor tenosynovitis (PFT) is a severe condition, and many patients report serious postoperative complications such as amputation, limited range of motion (ROM), or recurrence of symptoms. However, the ideal protocol for PFT treatment remains unknown owing to the limited number of studies. This retrospective cohort study aimed to identify prognostic factors for PFT treatment outcomes.

MATERIALS AND METHODS

Sixty-six patients (46 men and 20 women) with PFT who underwent surgical debridement at our hospital between September 2005 and January 2023 were included in this study. We conducted multivariate linear regression analysis with permanent deficit as the primary outcome. We defined the number of operations, laboratory data, interval from onset to debridement, previous conservative treatment, aetiology, Kanavel's signs, and medical history of diabetes mellitus as possible prognostic factors. We also defined the interval from onset to debridement as a secondary outcome and performed logistic regression analysis.

RESULTS

Overall, 25 (38%) patients had postoperative deficits. Longer interval from onset to surgery (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.0-1.1) and polymicrobial infection (OR: 7.8, 95% CI: 1.56-38.8) were significant prognostic factors for unfavourable outcomes. Additional multivariate analysis showed that preoperative conservative treatment prolonged the interval to surgery (estimate, 16.4; standard error, 1.6; p < 0.05).

CONCLUSIONS

The results of this study suggest that indications for nonoperative treatment of PFT are limited and that earlier surgical debridement is recommended.

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.

Primary skin abscess microbiota a systematic review

An abscess is a collection of pus forming a cavity in the tissue, for example, the skin. They are generally perceived as the result of infection but infection is not mandatory for the diagnosis. Skin abscesses may occur independently (primary) or be part of other diseases such as the recurrent inflammatory skin disease hidradenitis suppurativa (HS). HS is noninfectious but nevertheless abscesses are a common differential diagnosis. The purpose of this study is to review the microbiome of bacteria positive primary skin abscesses in order to explore the reported microbiota. EMBASE, MEDLINER, and COCHRANE LIBRABRY were searched on 9th of October 2021 for microbiome, skin, and abscesses. Studies with more than 10 patients reporting the microbiome in human skin-abscesses were included and studies with abscess microbiota sampled from HS patients, microbiota not sampled from skin-abscesses, missing information on microbiome data, sampling bias, studies in other language than English or Danish, reviews and meta-analyses were excluded. In total 11 studies were included for further analysis. S. aureus is likely to dominate the microbiome of bacteria positive primary skin abscesses in contrast to the polymicrobial microbiome of HS.

Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis

BACKGROUND

Pyogenic flexor tenosynovitis (PFT) has been considered a surgical emergency. Varying operative approaches have been described, but there are limited data on the method, safety, and efficacy of nonoperative or bedside management. We present a case series where patients with early flexor tenosynovitis are managed using a limited flexor sheath incision and drainage (I&D) in the emergency department (ED) to both confirm purulence within the flexor sheath and as definitive treatment.

METHODS

A retrospective study of all patients clinically diagnosed in the ED with flexor tenosynovitis at our institution from 2012 to 2019 was performed. Patients with frank purulence on examination were taken emergently to the operating room (OR). Patients with equivocal findings underwent limited flexor sheath I&D in the ED. Safety and efficacy were studied for patients with early flexor tenosynovitis managed with this treatment approach.

RESULTS

Thirty-four patients met the inclusion criteria. Ten patients underwent direct OR I&D, and 24 patients underwent ED I&D. In the ED I&D group, 96% (24 of 25) of patients did not have frank purulence in the flexor sheath and were managed with bedside drainage alone. There were no procedural complications and no need for repeat operative intervention. Time to intervention (3.1 hours vs 8.4 hours) was significantly shorter for the ED I&D group compared with the OR I&D group. Within the ED I&D group, 86% of patients exhibited good/excellent functional scores.

CONCLUSIONS

Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis.

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.

A Nationwide Epidemiological Analysis of Finger Infections Presenting to Emergency Departments in the United States From 2012 to 2016

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.

Optimizing Treatment of Hand Infections: Is MRSA Coverage Always Necessary?

Multiple publications have highlighted the prevalence of methicillin resistant Staphylococcus aureus (MRSA) as a cause of hand infections. We hypothesized that these publications have shifted the empiric treatment of hand infections. The aim of this study was to identify the current standard of care, the most common causative bacteria, and factors leading to extended length of stay for hand infection patients at a suburban hospital to improve treatment and establish an optimized care protocol.

Methods

Retrospective cohort analysis was conducted to identify all patients admitted for hand infections over an 8-year period. A comprehensive chart review of each patient's hospital course was completed.

Results

A total of 70 patients were included. Maximum white blood cell count ≥ 12 was associated with a significantly longer hospital length of stay (9.1 days versus 5.4 days) compared to WBC values < 12 (P < 0.05). Also, 11 out of 23 (47.8%) underwent two or more incision and drainages (I&D's), compared with patients with maximum WBC < 12. Vancomycin use as an empiric antibiotic was widespread (68 patients, 97.1%), despite only 14 (20%) having MRSA positive cultures. Univariate analysis identified a significant increased likelihood for increased length of stay (P < 0.05) and rise in creatinine (P < 0.05) in patients with an initial vancomycin trough level > 20.

Conclusions

This analysis of hand infection treatment in a suburban hospital demonstrates the incidence of MRSA hand infections may not be universally high across institutions. Each hospital should review its own data to optimize hand infection treatment and its associated costs.

Diagnosis and Management of Common Hand Infections

While many hand infections are superficial, diligent evaluation, diagnosis, and treatment of these infections are central for preventing disability and morbidity. Maintaining a wide differential diagnosis is important as some hand infections may mimic others. In geographic areas with more than a 10% to 15% prevalence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) hand infections, empiric antibiotics should adequately cover MRSA. Once culture results are available, antibiotic regimens should be narrowed to reduce the development of resistant pathogens.

A Rare Paronychia with Superinfection with Prevotella bivia and Staphylococcus haemolyticus: The Importance of Early Microbiological Diagnosis

Prevotella bivia is an anaerobic, gram-negative bacillus which naturally thrives in the human vagina, and is usually related to vaginal tract infections. However, this microorganism can also cause infections in other body locations. Infections with Prevotella bivia are frequently severe due to the risk of osteomyelitis and the lack of good protocols for adequate therapeutic management. Staphylococcus haemolyticus infection is one of the most frequent etiological factors of nosocomial infections, which hasthe ability to acquire multiple resistance against antimicrobial agents. We report a rare case of foot and hand paronychia with superinfection of Prevotella bivia and Staphylococcus haemolyticus. We highlight the importance of early microbiological diagnosis, and proper therapeutic management to avoid the risk of complications and the development of bacterial resistance to antibiotics.

Hand Abscesses: Volar and Dorsal

A high index of suspicion coupled with excellent knowledge of hand anatomy and function allows for accurate diagnosis and effective management of deep space infections. This article describes surgical approaches for closed-space infections. Drainage, debridement, and intraoperative irrigation are initial steps along with the decision for continuous postoperative irrigation based on intraoperative findings. Focused and thorough postoperative evaluation and antibiotics lead to successful management of these soft tissue deep abscesses. An experienced hand therapist should be involved early in recovery process to guide wound care along with passive assisted and active range of motion exercises of the wrist and digits.

Hand and Upper Extremity Infections in Intravenous Drug Users: Epidemiology and Predictors of Outcomes

PURPOSE

Injectable drug use (IDU) is a national epidemic, public health problem, and common cause of hand and upper extremity (UE) infections. This study assesses the epidemiology of the IDU patient population presenting to a Midwestern academic medical center emergency department (ED) and examines predictors influencing morbidity and outcomes.

METHODS

A retrospective review was performed using International Classification of Diseases, Ninth Revision (ICD-9) codes to identify all adult patients presenting to the ED with hand/UE infections, with and without concurrent IDU diagnoses, over a period of 2.5 years. Demographics and clinical factors were examined utilizing bivariate and multivariable analyses to identify predictors of outcomes, including not completing outpatient follow-up and leaving against medical advice (AMA).

RESULTS

A total of 1,482 patients with 1,754 ED visits for hand/UE infections were identified, including 308 patients with IDU-acquired infections (396 visits) and 1,174 patients with non-IDU infections (1,358 visits). Psychiatric comorbidities and hepatitis C were common in the IDU group (51% and 39%, respectively), and 31% of IDU patients were uninsured. Heroin use was identified in 96% of visits. The IDU infections were more likely to have surgical intervention than those in non-IDU patients (16% vs 6%), and a longer mean length hospital stay (2.4 vs 0.9 days). The IDU patients were more likely than non-IDU patients to leave AMA. In multivariable analysis, IDU, psychiatric comorbidity, and insurance status were independent predictors (P < .05) for leaving AMA.

CONCLUSIONS

In the setting of a national epidemic, hand/UE infections due to IDU are a common problem seen by hand surgeons. This study characterizes the growing IDU patient population at an urban academic medical center, examining the largest cohort of these patients to date.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Closed Continuous Irrigation With Lidocaine and Immediate Mobilization for Treatment of Pyogenic Tenosynovitis

Pyogenic flexor tenosynovitis treatment consists of either closed continuous irrigation with sterile saline or antibiotic solution, or open debridement and irrigation. These treatment approaches serve to resolve the infection, but are extremely painful and residual stiffness can be devastating to the patient. We describe herein our approach to managing pyogenic flexor tenosynovitis. To provide continuous irrigation, a butterfly catheter with needle removed is utilized with irrigation holes cut into the tubing. The catheter is inserted into the tendon sheath at the level of the Al pulley and brought out at the level of the A5 pulley. A knot is tied in the end of the catheter for retention, eliminating the need for sutures. Immediately postoperative, continuous irrigation with sterile saline mixed with lidocaine is initiated and is titrated to achieve pain-free motion in the finger. Occupational therapy begins an aggressive course of active and passive range of motion exercises immediate postoperatively, which is continued for the remainder of hospitalization. Our approach of continuous infusion of a lidocaine solution allows for pain-free movement immediately postoperatively to mechanically debride tissue, as well as allow for early active range of motion. We have obtained excelleepaknt results with this technique in all of our cases.

Pyogenic Arthritis of the Fingers and the Wrist: Can We Shorten Antimicrobial Treatment Duration?

Background

Pyogenic arthritis of the small joints of the hand and wrist is a known but poorly described entity. The objective of this work was to characterize the clinical presentation, antimicrobial treatment, and surgical interventions of native small joint arthritis (SJA) treated in our tertiary center.

Methods

According to predefined variables, medical records of adult patients with SJA treated in a Swiss university hospital between 2005 and 2013 were retrospectively analyzed.

Results

The median age of 97 patients (101 joints) was 52 years (interquartile range [IQR], 38–68 years); 52% had no comorbidity. Small joint arthritis of the second and third fingers accounted for 53% of infections, with metacarpal-phalangeal and proximal interphalangeal joints most commonly involved. Of 86 (89%) episodes with an exogenous source, 63 (65%) followed a trauma. The most commonly isolated microorganism was Staphylococcus aureus (38%), followed by β-hemolytic streptococci (13%) and Pasteurella spp (11%). Eighty-seven episodes (89 joints) in patients with follow-up examinations were included in treatment and outcome analyses. Up to 2 surgical interventions were required to cure infection in 74 (83%) joints. Median antimicrobial treatment duration was 14 days (IQR, 12–28 days), with amoxicillin/clavulanate administered in 74 (85%) episodes. At follow up, cure of infection was noted in all episodes and good functional outcome in 79% of episodes.

Conclusions

Small joint arthritis shows considerable differences from clinical patterns reported for larger joints. In our series, the outcome was good with no more than 2 surgical interventions and median treatment duration of 14 days in 79% of episodes.

Septic Arthritis of the Small Joints of the Hand

Twenty-five patients with sepsis of 26 hand joints were treated by urgent debridement, antibiotics and early hand therapy. We reviewed 15 patients (16 joints) in a clinic and three patients by postal questionnaire after a mean follow-up of 54 (range 10–94) months. Of the 26 involved joints, 14 had restricted motion at discharge. Stiffness increased with increase in delay between onset and treatment. At final review, one joint with painful degenerative changes had been fused. Seven patients had regained full movements. The remaining six had some stiffness but, nevertheless, had undergone significant improvement in the ranges of movement. There were two cases with radiological joint degeneration in this group of six patients. Three patients had mild, intermittent pain. No patient had significant disability. While there is significant loss of motion after this joint pathology in the early recovery period, overall motion and function appears to improve over the longer term.

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.

Bite injuries to the hand: microbiology, virology and management

Bites to the human hand, be it from a pet, a stray animal or even a fellow human, may often have dire consequences for the person suffering the insult. Bites by mammals are a common problem and they account for up to 1% of all visits to hospital emergency rooms, in the UK. Clenched fist injuries to the mouth ('fight bite') are notorious for being the worst human bites. Bite injuries of the hand and their related infections must be monitored vigilantly and managed proactively, by experts in this field of surgery. In this review article we discuss the associated microbiology and virology of these injuries as well as their management.

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.

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.

Pyogenic flexor tenosynovitis in children

Pyogenic flexor tenosynovitis is an uncommon, emergent hand infection. The literature lacks any description of the disease and the variability of its manifestations in young children. We describe 3 cases. Two cases were diagnosed and treated promptly, and the third presented late, with atypical clinical signs, causing a delay in his diagnosis and treatment and stressing the caution to be taken with the evaluation of these children with signs of hand infection.

Can paronychia cause a remote necrotizing soft tissue infection?

Remote necrotizing soft tissue infection (NSTI) resulting from paronychia is very unusual but potentially lethal. We report a case of a 39-year-old woman affected by this unusual infection. The paronychia completely resolved in less than 2 weeks, however, a NSTI involved the right chest and flank and the left thigh. The patient required intensive care and multiple surgical debridements. This recent experience and literature data suggest that paronychia can cause a remote NSTI that can rapidly spread and become life-threatening. Broad spectrum antibiotics and aggressive surgical debridement are essential to a successful outcome.

Purulent flexor tenosynovitis: factors influencing the functional outcome

This retrospective study aimed to evaluate the factors that influence the final outcome of treatment of purulent flexor tenosynovitis, viz. delay in treatment, severity of the condition, the infecting pathogen and the method of treatment. Of 41 patients with this condition treated by drainage and irrigation through two small incisions (16) and wide incision (25), 16 were treated after a delay. Continuous postoperative irrigation was applied in 26 patients. Re-operation was necessary in 11 patients. In most cases, Staphylococcus aureus was detected. The results were excellent in 32 cases and the mean Disabilities of the Arm, Shoulder and Hand score was 8.1. Irrigation through small incisions and continuous postoperative irrigation decreased the probability of an unfavourable outcome. Delayed treatment and infections with specific pathogens led to a worse outcome. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear, from this retrospective review, to lead to the best functional outcome.

Compartmental infections of the hand

Suppurative conditions of the hand-wrist compartments result in a "vicious circle" of infection and increase in compartmental pressure that reduces perfusion of soft tissues and facilitates spreading of the infection. We have assessed the outcome of such infections in relation to the infecting pathogen, delay in diagnosis, and method of treatment. Fifty-nine patients were treated with drainage, irrigation, and antibiotics and followed up for 6-58 (median 18) months. Staphylococcus aureus was detected in 29 of 39 cultures (74%) that grew pathogens. At the latest follow-up results were excellent in 49 cases. Sixteen required reoperation or readmission. There was a significant association between final range of movement (ROM) and extent of infection (p=0.01). The type of pathogen was also significantly associated with a worse outcome (p=0.03 for ROM, p=0.04 for DASH). These infections have poor results when treatment is delayed or inadequate, as a result of the extended infection, inadequate drainage or inappropriate antibiotic treatment of certain types of bacteria.

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.