Hand infections

Looped Penrose Drainages of Acute Hand Infections in Vulnerable Populations

PURPOSE

Acute hand infections (AHIs) remain a challenge for hand surgeons and represent a condition for which clinical outcomes are considerably affected by social barriers. We previously described the looped Penrose drainage technique, where a drain is sutured to itself in a loop and the outflow tract of egress is maintained, thus obviating the need for large incisions, wound closure, or repeat packing, thereby reducing the follow-up burden. In the face of escalating numbers of socioeconomically vulnerable patients, especially in urban settings, we aimed to characterize the clinical features and outcomes of this technique in an urban population of patients with AHI.

METHODS

A review of all surgical irrigations of AHI by a single, fellowship-trained hand surgeon at an urban hospital from 2013 through 2021 was performed. Patient demographics, procedure details, and postprocedure outcomes were analyzed.

RESULTS

Fifty-three patients (average age, 48.6 years) with AHI underwent surgical irrigations with the looped Penrose drainage technique. The majority of patients were Black (50.9%). Approximately 81.1% of the patients received public insurance, 22.6% were unemployed, 35.9% had annual incomes <$40,000, and 17% experienced homelessness. Overall, 34% were lost to follow-up with the Penrose still intact, including 78% of those who were homeless. Most of the cases occurred on the hand, with involvement of the deep spaces (24.5%), tenosynovitis (39.3%), and bone (1.9%). Recurrent infection (1.9%) and abscess formation (5.7%) led to one reoperation (1.9%). There were no amputations or readmissions, and all postoperative emergency department visits (7.1%) were discharged.

CONCLUSIONS

The looped Penrose technique is a simple and less invasive alternative to traditional incision and drainage with packing and serves as an effective single-episode intervention strategy for AHIs, particularly in patients with complex social challenges because of the ease of wound management and low rates of readmission and reoperation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Establishing the Role of Inflammatory Markers in the Diagnosis and Treatment of Acute Hand Infections in the Pediatric Population

INTRODUCTION

Distinguishing the severity of the diagnosis and an appropriate treatment plan in pediatric hand infections can be complex due to the variable amount of information available at the presentation. Inflammatory blood markers, including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are reported to aid in determining the severity of infection and response to treatment in adult hand infections. The purpose of this study was to identify the relevance of inflammatory marker levels in pediatric patients with hand and wrist infections and to determine their utility in diagnosis and treatment.

METHODS

This multicenter, retrospective, cohort study included patients aged 0 to 18 who received treatment for an acute hand or wrist infection between 2009 and 2020. Data collected included demographics, time to presentation, diagnosis, inflammatory markers, culture results, antibiotic treatment, and surgical treatment. Infections were categorized as deep (osteomyelitis, tenosynovitis, abscess) and superficial (paronychia, felon, cellulitis). Exclusion criteria included: patients above 18 years of age, chronic infection, open fractures, and absence of any documented inflammatory markers. Statistically, t tests were used to compare mean differences in inflammatory markers between patients who did and did not receive pretreatment antibiotics and between patients who had superficial versus deep hand infections.

RESULTS

A total of 123 patients met the inclusion criteria. Pretreatment with antibiotics before definitive management was not significantly associated with differences in laboratory markers compared with patients not pretreated with antibiotics. Deep hand infections had inflammatory markers similar to superficial infections. Patients with deep hand infections required a bedside or operative procedure 78.9% of the time compared with superficial infections (21.2%) ( P <0.001). Patients with an isolated methicillin-resistant Staphylococcus aureus infection had inflammatory marker values that were not significantly different from patients infected with all other microbes.

CONCLUSIONS

Inflammatory markers were not significantly different between patients who received pretreatment with antibiotics and those who did not. While deep infections were often treated with bedside or surgical procedures, the inflammatory marker values were similar to those of superficial infections. The same held true for patients infected with culture-positive, isolated methicillin-resistant Staphylococcus aureus bacteria. Consequently, inflammatory markers may be useful to identify the presence of infection and monitor the response to treatment, they did not aid in determining the specific type of infection or selection of a treatment plan.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Microbiologic Analysis of Hand Infections: A Prospective Study

Background: Hand infections are a common problem in emergency departments. Staphylococcus aureus is the main pathogen of both hand and blood stream infections. Therefore, the aim of the present study was to evaluate the frequency and impact of bacteremia in patients with hand infections to improve the microbiologic diagnostics. Patients and Methods: A prospective study of 90 patients with acute hand infections without antimicrobial pre-treatment was performed. Blood cultures were taken pre-operatively. If positive, transesophageal echocardiography was performed to rule out infectious endocarditis. Tissue samples were microbiologically processed using standardized culture media. If negative, a broad-spectrum bacterial 16S ribosomal RNA (rRNA) gene polymerase chain reaction (PCR) was applied. The etiology and location of the infection, the length of hospital stay, the number of surgical interventions, and the inflammatory parameters were obtained. Results: Six patients with bacteremia (6.6%) were diagnosed, after animal bites (n = 3) and intra-articular empyema (n = 3). Pathogens included Staphylococcus pettenkoferi, Pasteurella multocida, Staphylococcus epidermidis, Staphylococcus aureus, and Bacteroides pyogenes. No case of infective endocarditis was detected. Patients with bacteremia required more surgical interventions (p = 0.002), had a longer hospital stay (p < 0.001), higher plasma C-reactive protein (CRP; p = 0.016), and a higher age (p = 0.002) compared with those without bacteremia. In 14 cases (15.6%) no pathogen was detected by culture, whereas the subsequent broad-spectrum PCR diagnosed three cases (21.4%). Conclusions: Pre-operative blood cultures in patients with hand infections are important to detect bacteremia as an essential marker of clinical severity. Those blood cultures are indicated after deep animal bites and joint empyema. A precise identification of pathogens is fundamental for an effective treatment of hand infections, for which a 16S rRNA gene PCR can contribute in culture-negative tissue samples.

[Evaluation of the Charlson Comorbidity Index as a prognostic tool for assessing the severity of hand infections]

BACKGROUND

The Charlson Comorbidity Index (CCI) is used for the prognostic analysis of comorbidities. Comorbidities, especially diabetes mellitus, are a decisive factor for the development and course of hand infections. This study aimed to determine the CCI in patients with hand infections in order to examine how comorbidities influence the course and severity of hand infections.

MATERIAL AND METHODS

Ninety patients with hand infections requiring surgery but without previous antibiotic treatment were studied prospectively. The respective CCI was determined on admission to hospital. A total score of zero points was defined as "low", a score of one to three as "medium" and a score of four to nine points as a "high" index. Age, CRP level, duration of inpatient stay and the number of performed surgeries were documented and statistically evaluated.

RESULTS

The median CCI was 0,5 points with a range of 0-9 points. The most common comorbidity was diabetes mellitus without end-organ damage, followed by heart failure and chronic lung disease. Patients with a low total score (median 51 years) were significantly younger than those with a medium score (median 60 years; p=0,018) or a high score (median 66,5 years; p=0,018). In addition, patients with a low or medium score had a shorter hospital stay (median 6 vs. 11,5 days; plow=0,003; pmean=0,005), required fewer surgeries (median 1 vs. 3 surgeries; plow=0,002; pmean=0,003) and had a lower CRP level (median 8,3 mg/l vs. 7,1 mg/l vs. 86,25 mg/l; plow=pmean=0,001) than those with a high index. A significant positive correlation was found between the CCI and patient age (Spearman's ρ=0,367; p<0,001) as well as the length of hospital stay (Spearman's ρ=0,261; p=0,013), the number of surgeries (Spearman's ρ=0,219; p=0,038) and the CRP level (Spearman's ρ=0,212; p=0,045).

CONCLUSIONS

The CCI is an appropriate questionnaire for the prognostic assessment of the course and severity of hand infections, particularly with regard to the length of hospital stay, the number of surgeries and the CRP level.

Upper Extremity Infections in the Transplant Population

PURPOSE

As the duration of lifetime survival after organ transplantation continues to increase, the consequences of long-term immunosuppression, such as opportunistic and rare infections, are a high-risk reality. This study examined upper extremity infections in the transplant population to determine the current clinical risk profile, management, and outcomes.

METHODS

An institutional database of 16,640 patients who underwent transplantation was queried for upper extremity infections from 2005 to 2017, defined as the presence of infection from the shoulder to the fingertips. The resulting data were analyzed using multivariable linear and logistic regression modeling.

RESULTS

A total of 230 eligible patients experienced upper extremity infections at a mean age of 54.1 ± 15.3 years, occurring, on average, 7.9 ± 8.6 years after transplantation. The most commonly transplanted organ was the kidney (51.3%), followed by the liver (20%). The most common location of infection was the forearm (31.7%), digits (27.4%), and upper arm (17%). The most common types of infection were cellulitis (69.1%), abscess (33.5%), joint sepsis (6.5%), infectious tenosynovitis (3.9%), and osteomyelitis (1.3%). Patients taking an antifungal medication, those who had a joint infection, or those who had undergone lung transplantation had an approximately 2.5-day longer stay in the hospital. For every 1-year increase in age at the time of transplantation, the time from transplantation to infection decreased by 0.21 years. Those who had undergone bone marrow transplantation or those who were taking tacrolimus were expected to have approximately 8- and 6-year decreases, respectively, in the time from transplantation to infection.

CONCLUSIONS

Upper extremity infections should be individually evaluated and treated because of the heterogeneity of transplant type, immunosuppression medications, the age of the patient, and infection characteristics.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Acute upper limb infections in a regional Scottish plastic surgery unit during COVID-19: lessons learned

Acute upper limb infections represent a large proportion of on-call referrals and emergency theatre time in plastic surgery. To enable us to maintain effective service provision despite reallocation of hospital resources as a result of COVID-19, and to minimise patient exposure in a hospital setting during the pandemic, we introduced a walk-in clinic and dedicated local anaesthetic (LA) operating theatre for these infections. In this work, we sought to analyse our service changes and resulting patient outcomes. Using electronic records, data from patients presenting with upper extremity infections was collected before the pandemic from 1st January to 30th March 2020, then for a period of three months from 30th March until 30th June 2020, after our changes were implemented. Seventy-two patients were included before 30th March 2020, and 49 patients after. Prior to our changes, most patients underwent surgery (n = 58, 80.6%), requiring overnight admission (n = 64, 88.9%), following mainly general anaesthetic procedures (n = 56, 96.6%). After our service changes, a similar percentage of patients were treated operatively (n = 41, 83.7%), but these procedures mostly utilised LA (n = 37, 90.2%) in the outpatient setting (n = 25, 51.0%). Despite this shift in management approach, no statistically significant difference in readmission rates was calculated between the two groups (p = 0.556) and post-operative complications were fewer in absolute terms. Our results suggest that in many instances, these infections can be managed in an outpatient setting without the need for inpatient care. Selective admission with strict follow-up of patients may be feasible, improving patient experience and reducing resource burden.

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.

Oral Antibiotic Management of Acute Osteomyelitis of the Hand: Outcomes and Cost Comparison to Standard Intravenous Regimen

Background: Acute, direct inoculation osteomyelitis of the hand has traditionally been managed by intravenous antibiotics. With proven high levels of bone and joint penetration, specific oral antimicrobials may deliver clinical efficacy but at substantially lower cost. Methods: Sixty-nine adult patients with surgically proven acute, direct inoculation osteomyelitis of the hand were evaluated for clinical response on a 6-week postdebridement regimen of susceptibility-matched oral antibiotics. Inclusion required gross purulence and bone loss demonstrated at the initial debridement and radiographic evidence of bone loss. Excluded were 2 patients with extreme medical comorbidities. There were 53 men and 16 women with a mean age of 46 years. Mean follow-up was 16 weeks (±10). The cost model for the outpatient oral antibiotic treatment was intentionally maximized using Walgreen's undiscounted cash price. The cost model for the traditional intravenous treatment regimen was intentionally minimized using the fully discounted Medicare fee schedule. Results: All patients achieved resolution of osteomyelitis by clinical and radiographic criteria. In addition, 7 patients underwent successful subsequent osteosynthesis procedures at the previously affected site without reactivation. The mean postdebridement direct cost of care per patient in the study cohort was $482.85, the cost of the antibiotic alone. The postdebridement direct cost of care per patient on a regimen of vancomycin 1.5 g every 12 hours via peripherally inserted central catheter line was $21 646.90. Conclusions: Acute, direct inoculation osteomyelitis of the hand can be successfully managed on oral antibiotic agents with substantial direct and indirect cost savings.

[Septic Arthritis of the Hand and Wrist]

This review article addresses the epidemiology, ethology, clinic, diagnostics and therapy of infections of the wrist and small joints of the hand.

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.

The effects of a UK lockdown on orthopaedic trauma admissions and surgical cases: A multicentre comparative study

Aims

The current global pandemic due to COVID-19 is generating significant burden on the health service in the UK. On 23 March 2020, the UK government issued requirements for a national lockdown. The aim of this multicentre study is to gain a greater understanding of the impact lockdown has had on the rates, mechanisms and types of injuries together with their management across a regional trauma service.

Methods

Data was collected from an adult major trauma centre, paediatric major trauma centre, district general hospital, and a regional hand trauma unit. Data collection included patient demographics, injury mechanism, injury type and treatment required. Time periods studied corresponded with the two weeks leading up to lockdown in the UK, two weeks during lockdown, and the same two-week period in 2019.

Results

There was a 55.7% (12,935 vs 5,733) reduction in total accident and emergency (A&E) attendances with a 53.7% (354 vs 164) reduction in trauma admissions during lockdown compared to 2019. The number of patients with fragility fractures requiring admission remained constant (32 patients in 2019 vs 31 patients during lockdown; p > 0.05). Road traffic collisions (57.1%, n = 8) were the commonest cause of major trauma admissions during lockdown. There was a significant increase in DIY related-hand injuries (26% (n = 13)) lockdown vs 8% (n = 11 in 2019, p = 0.006) during lockdown, which resulted in an increase in nerve injuries (12% (n = 6 in lockdown) vs 2.5% (n = 3 in 2019, p = 0.015) and hand infections (24% (n = 12) in lockdown vs 6.2% (n = 8) in 2019, p = 0.002).

Conclusion

The national lockdown has dramatically reduced orthopaedic trauma admissions. The incidence of fragility fractures requiring surgery has not changed. Appropriate provision in theatres should remain in place to ensure these patients can be managed as a surgical priority. DIY-related hand injuries have increased which has led to an increased in nerve injuries requiring intervention.

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.

Risk factors for reoperation in primary hand infections: a multivariate analysis

INTRODUCTION

Severe hand infection might cause severe morbidity including stiffness, contracture and possibly amputation. The purpose of this study was to analyse the current epidemiology of adult acute hand infections in a European Hand Surgery Centre and to identify risk factors for secondary surgery.

MATERIALS AND METHODS

We retrospectively analyzed a cohort of 369 consecutive patients with primary infection of the hand that were admitted to our department and required operative treatment. The following variables were recorded: demographics, medical history, cause and location of infection, laboratory values, cultured microorganisms and reoperation rate. Univariate logistical regression was used to identify variables associated with reoperation and backward selection was applied to identify the final multiple variable model.

RESULTS

The mean age at the time of operation was 50.5 years (SD 16.1, range 19-91) and 65.6% of patients were male. Sharp cuts or lacerations were the most common cause (29.0%) for hand infections. 81 different species were cultivated and in 47 patients (12.7%), the cultures were positive for more than one organism. Staphylococcus aureus was the most common cultured organism (19.5%). There were relatively few cases of methicillin-resistant Staphylococcus aureus (2.2%). 80 patients (21.7%) needed more than one operation. We identified three risk factors for reoperation in a multivariate analysis: an elevated value of C-reactive protein at the time of admission, involvement of multiple sites and bacterial growth in culture.

CONCLUSION

The rate of infections with MRSA in this European cohort was lower compared to reports from the USA. Thus, hand surgeons should choose their empiric antibiotic therapy depending on their patient population. The knowledge of risk factors for severe hand infections might help surgeons to identify patients at risk for additional surgery early.

Development and Validation of a Prognostic, Risk-Adjusted Scoring System for Operative Upper-Extremity Infections

PURPOSE

Acute infections of the distal upper extremity (UE) can require one and possibly multiple debridements. We aimed to develop and validate a prognostic scoring system based on patient, infection, and microbiology risk factors to help with operative planning and patient counseling.

METHODS

We studied all acute surgical UE infections distal to the elbow joint over a 5-year period. A split-sample design was created with 1:1 randomization into development and validation samples. The primary outcome was infection persistence, defined as the need for additional operative drainage according to usual indications. Multivariable logistic regression identified risk factors for persistent infections in the development sample, which was translated to a simple clinical scoring system derived from regression coefficients. The model was then tested separately against the validation sample.

RESULTS

A total of 602 patients were included; 31% of all infections exhibited persistence. Independent risk factors from the development sample included diabetes (3 points), smoking (2 points), leukocytosis at presentation (2 points), animal bite mechanism (3 points), osteomyelitis (4 points), tenosynovitis (7 points), pyarthrosis (3 points), necrotizing fasciitis (11 points), and methicillin-resistant Staphylococcus aureus (3 points). These were all confirmed in the validation sample. Infections were categorized into 3 groups based on risk for persistent infection: low (less than 8 points), medium (8-11 points), and high (12 points or more). In the validation sample, the probability of persistent infection for these 3 groups was 23%, 57%, and 79%, respectively. The c statistic for the model in the validation sample was 0.79.

CONCLUSIONS

Persistence of acute surgical distal UE infections is mediated by patient and microbiology factors, as well as infection mechanism and type. Surgeons can use this risk-adjusted prognostic scoring system to anticipate which infections may require additional therapeutic debridement and plan operative schedules and counsel patients accordingly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

MRSA Incidence and Antibiotic Trends in Urban Hand Infections: A 10-Year Longitudinal Study

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is the most reported pathogen in hand infections at urban medical centers throughout the country. Antibiotic sensitivity trends are not well known. The purposes of this study were to examine and determine the drug resistance trends for MRSA infections of the hand and to provide recommendations for empiric antibiotic treatment based on sensitivity profiles. Methods: A 10-year longitudinal, retrospective chart review was performed on all culture-positive hand infections encountered at a single urban medical center from 2005 to 2014. The proportions of all organisms were calculated for each year and collectively. MRSA infections were additionally subanalyzed for antibiotic sensitivity. Results: A total of 815 culture-positive hand infections were identified. Overall, MRSA grew on culture in 46% of cases. A trend toward decreasing annual MRSA incidence was noted over the 10-year study period. There was a steady increase in polymicrobial infections during the same time. Resistance to clindamycin increased steadily during the 10-year study, starting at 4% in 2008 but growing to 31% by 2014. Similarly, levofloxacin resistance consistently increased throughout the study, reaching its peak at 56% in 2014. Conclusions: The annual incidence of MRSA in hand infections has declined overall but remains the most common pathogen. There has been an alternative increase in the number of polymicrobial infections. MRSA resistance to clindamycin and levofloxacin consistently increased during the study period. Empiric antibiotic therapy for hand infections should not only avoid penicillin and other beta-lactams but should also consider avoiding clindamycin and levofloxacin for empiric treatment.

Hand Infections

Hand infections can lead to debilitating and permanent disability, particularly if they are not treated promptly or properly. The unique anatomy of the hand, with its numerous enclosed and confined spaces, warrants special considerations. For instance, infections in deep spaces of the hand may require surgical drainage despite an appropriate course of antimicrobial treatment. Thorough history and examination are crucial in guiding further investigations and management, particularly because there are numerous mimickers of hand infections, such as gout and pseudogout.

Infections of the hand: an overview

Infections of the hand are common entities that are frequently encountered by orthopaedic surgeons and primary care physicians.

A high clinical suspicion and a thorough medical history with information about the social and working history of the patients, correct identification of the type and cause of the infection, and prompt initiation of appropriate treatment by the infectious diseases physicians and orthopaedic surgeons are required.

Late diagnosis and inappropriate treatment may be a significant cause of morbidity for the hand and mortality for the patients. This article reviews the clinical spectrum and microbiology of the most common infections of the hand, and discusses the current concepts for their treatment. The aim is to increase the awareness of the treating physicians of the diagnosis and management of infections in the hand.

Cite this article: EFORT Open Rev 2019;4:183-193. DOI: 10.1302/2058-5241.4.180082

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.

The Anconeus Muscle Free Flap: Clinical Application to Lesions on the Hand

BACKGROUND

It can be difficult to select an appropriate flap for various defects on the hand. Although defects of the hand usually must be covered with a skin flap, some defects require a flap with rich blood supply and adequate additive soft tissue volume. The authors present their experience with the anconeus muscle free flap in the reconstruction of various defects and the release of scar contractures of the hand.

METHODS

Ten patients underwent reconstruction of the finger or release of the first web space using the anconeus muscle free flap from May 1998 to October 2013. Adequate bed preparations with thorough debridement or contracture release were performed. The entire anconeus muscle, located at the elbow superficially, was harvested, with the posterior recurrent interosseous artery as a pedicle. The defects were covered with a uniformly trimmed anconeus muscle free flap. Additional debulking of the flap and skin coverage using a split-thickness skin graft were performed 3 weeks after the first operation.

RESULTS

The average flap size was 18.7 cm2 (range, 13.5-30 cm2). All flaps survived without significant complications. Vein grafts for overcoming a short pedicle were necessary in 4 cases.

CONCLUSIONS

The anconeus muscle free flap can be considered a reliable reconstructive option for small defects on the hand or contracture release of the web space, because it has relatively consistent anatomy, provides robust blood supply within the same operative field, and leads to no functional loss at the donor site.

Acute Deep Infections of the Upper Extremity: The Utility of Obtaining Atypical Cultures in the Presence of Purulence

PURPOSE

In the setting of acute deep upper extremity infections, evidence is lacking to guide the decision whether to send atypical cultures (fungal and acid-fast-bacillus [AFB]) during surgical debridement, especially in the presence of purulent fluid that is commonly observed with typical bacterial infections. Our purpose was to determine the frequency of positive atypical cultures and the frequency with which they alter treatment, and identify factors associated with positive atypical cultures.

METHODS

We retrospectively identified 100 adult patients undergoing surgical debridement of acute deep infections of the upper extremity in which fungal and/or AFB cultures were sent. Necrotizing and superficial infections were excluded. Descriptive statistics were used to describe patient characteristics, infection diagnoses, number of cultures sent with corresponding rates of positivity, and treatments. Cohorts with positive and negative atypical cultures were compared with bivariate analysis for all collected variables.

RESULTS

One or more immunocompromising comorbidities were present in 46% of patients. Diagnoses included soft tissue abscess (46%), suppurative flexor tenosynovitis (22%), septic arthritis (21%), osteomyelitis (9%), and septic bursitis (2%). Aerobic bacterial, anaerobic bacterial, fungal, and AFB cultures were sent in 100%, 99%, 94%, and 82% of patients, respectively. Corresponding rates of positivity were 74%, 34.3%, 5.3%, and 2.4%, respectively. Atypical cultures were positive for 7% of patients and 2.9% of all atypical tests sent. Antibiotic treatment was influenced by atypical culture data for 4% of patients. For patients with positive atypical cultures, purulence was observed during surgery in 86% of cases. Bivariate analysis demonstrated symptom duration greater than 7 days as potentially associated with atypical culture positivity.

CONCLUSIONS

Intraoperative purulence at the time of surgical intervention should not deter the surgeon from obtaining atypical cultures. As expected, atypical cultures are infrequently positive given the rarity of associated diseases. Symptoms greater than 7 days may predict a higher incidence of atypical culture positivity for patients being treated surgically within 30 days of initial symptom onset.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Reconstruction of face and scalp after dog bites in children

ABSTRACT Objective: to evaluate the immediate reconstruction of face and scalp after canine bites in children. Methods: we conducted a prospective series of cases treated at the Emergency Unit of the Asa Norte Regional Hospital, Brasília - DF, from January 1999 to December 2014. At the time of patient admission to the emergency, the primary wound closure of the face and scalp bite was performed, regardless of the time or day of the event. The primary treatment of the bites was by means of direct suture, flaps rotation or grafting, depending on the type of wound and surgeon's decision. Results: the study comprised 146 children, with the zygomatic region and scalp being the main sites of head bites. All patients received surgical treatment within the first 24 hours after admission. There were no infectious complications in the cases studied. Conclusion: the findings suggest that the immediate closure of canine bites on the face and scalp in children is safe, even when carried out several hours after injury.

Hand infection patients presenting to an orthopaedic unit: An audit of incidence and demographics at a rural hospital

OBJECTIVE

Hand infections are a common presentation to health services in the Northern Territory; however, little is known about these patients. This study aims to identify incidence, treatment and co-morbidities of hand infection patients and to pinpoint factors associated with poor outcome.

DESIGN

A retrospective study of all patients presenting to Alice Springs Hospital with a hand infection during 2012.

SETTING

Orthopaedic Unit at Alice Springs Hospital.

PARTICIPANTS

All patients admitted with a hand infection were included.

MAIN OUTCOME MEASURES

Admission duration, duration waited before first presentation, re-admission rate, duration of re-admission and rate of methicillin-resistant Staphylococcus aureus.

RESULTS

One hundred fourteen cases of hand infections were admitted to Alice Springs Hospital during 2012, of which 87 (76%) were in Indigenous patients. Indigenous patients (P = 0.001) and older patients (P = 0.038) had significantly longer admissions. Indigenous patients were 9.52 times (P = 0.038) more likely to be re-admitted than non-Indigenous patients. The rate of methicillin-resistant Staphylococcus aureus was 24.6%, and this was associated with smoking (P = 0.049) and substance abuse (P = 0.036). Formal follow-up was not related to indirect measures of hand infection severity, such as admission duration or re-admissions.

CONCLUSION

Hand infections are a common presentation to Alice Springs Hospital. Indigenous people are admitted 2.38 times longer after adjusting for age and alcohol abuse. They have a more than ninefold chance of being re-admitted to hospital than non-Indigenous people following a hand infection.

Infection after hand surgery

Postoperative infections are uncommon after hand surgery. Infection can delay recovery and contribute to scarring and stiffness. Measures intended to reduce the risk of infection after hand surgery include hand washing, skin preparation, sterile technique, and prophylactic antibiotics. The role of prophylactic antibiotics for small, clean, elective hand surgery procedures lasting less than 2 hours is debated.

Acute hand infections

The continued emergence of antibiotic-resistant bacteria and the development of only a few new classes of antibiotics over the past 50 years have made the treatment of acute hand infections problematic. Prompt diagnosis and treatment are important, because hand stiffness, contractures, and even amputation can result from missed diagnoses or delayed treatment. The most common site of hand infections is subcutaneous tissue and the most common mechanism is trauma. An immunocompromised state, intravenous drug abuse, diabetes mellitus, and steroid use all predispose to infections.

Mammalian bite injuries to the hand and their management

Bite wounds are a common form of hand injury with the potential to lead to severe local and systemic sequelae and permanent functional impairment. Mammalian bite wounds may be caused by a variety of animal class and species; injuries resulting from dogs, cats and humans are the most widely discussed and reported in the literature. Bite wounds may be contaminated with aggressive pathogens and the anatomical vulnerability of structures within the hand means that without early recognition and treatment with irrigation and antibiotics, alongside a low index of suspicion for deep structural involvement requiring formal surgical exploration and washout, the consequences of such injuries can be disastrous. We review the literature and discuss the epidemiology, pathophysiology and microbiology relating to these injuries, as well as clinical aspects including signs, symptoms, and management.

Cochrane corner: antibiotic prophylaxis for mammalian bites (intervention review)

BACKGROUND

Bites by mammals are a common problem and they account for up to 1% of all visits to hospital emergency rooms. Dog and cat bites are the most common, and people are usually bitten by their own pets or by an animal known to them. School-age children make up almost a half of those bitten. Prevention of tetanus, rabies and wound infection are the priorities for staff in emergency rooms. The use of antibiotics may be useful to reduce the risk of developing a wound infection.

OBJECTIVES

To determine if the use of prophylactic antibiotics in mammalian bites is effective in preventing bite-wound infection.

SEARCH METHODS

Relevant randomized controlled trials (RCTs) were identified by electronic searches of MEDLINE, EMBASE, LILACS and the Cochrane Controlled Trials Register databases in November 2000.

SELECTION CRITERIA

We included randomized controlled trials that studied patients with bites from all mammals. Comparisons were made between antibiotics and placebo or no intervention. The outcome of interest was the number of infections at the site of the bite.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted the data independently. All analyses were performed according to the intention-to-treat method.