Infections of the hand: an overview

Tenosynovitis caused by Trichosporon asahii in an immunocompetent patient

BACKGROUND

Fungal infections have become a public health problem owingdute to their progressive increase in recent decades and high morbidity rates. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. Trichosporon spp. are yeast-like basidiomycetes, with Trichosporon asahii being the most common pathogenic species. This article describes a rare case of tenosynovitis caused by Trichosporon asahii in an immunocompetent patient. Treatment with voriconazole resulted in an excellent clinical response.

Quantitative risk assessment and interventional recommendations for preventing canine distemper virus infection in captive tigers at selected wildlife stations in Thailand

Canine distemper virus (CDV) can cause high morbidity and mortality in large felids and pose a significant threat to the conservation of captive and non-captive tiger (Panthera tigris). This study conducted in Thailand's wildlife stations aimed to assess the risks of CDV introduction to captive tiger populations. A stochastic quantitative risk assessment model was employed to determine the pathways and estimate the risk probabilities through humans, animal reservoirs, and fomites. The final risk probability of entry, obtained from a combination of six entry pathways, indicated that the absence of measures resulted in a relatively high risk at 0.858. The sensitivity analysis identified CDV-contaminated human hands, followed by other CDV-infected wild animals, and CDV-contaminated equipment, as the most influential pathways of CDV spread. Risk probabilities were compared among those without intervention, with routine intervention at wildlife stations, and with full intervention implementation. Implementing all interventions at the captive wildlife stations significantly reduced the risk of CDV introduction. These interventions included control measures such as quarantining and isolating infected animals and providing treatment to reduce infectiousness. Preventive measures included screening tests for healthy individuals for early detection of asymptomatic or pre-symptomatic cases, preventing further spread or complications, CDV vaccination campaigns, and promoting hand hygiene among staff and visitors. Environmental interventions involve restricting dogs and cats from accessing tiger enclosures, disinfecting animal transport vehicles, using separate equipment for each cage, etc. Together, these interventions lowered the median risk of CDV introduction to 0.089, representing an 89.6% risk reduction. This approach assessed CDV infection risks and adapted interventions to specific situations at wildlife stations. Consistent implementation of these measures is essential to minimize CDV spread. Wildlife stations must strictly implement these interventions as standard procedures to protect the health of captive tigers.

Diagnostic Challenges and Complex Surgical Management of an Atypical Mycoplasma Infection From a Cat Scratch: A Case Report

CASE

A 58-year-old veterinarian presented with a dorsal-radial hand and wrist infection after a catch scratch. Despite multiple courses of broad-spectrum antibiotics, her symptoms progressed culminating in rupture of the first dorsal compartment tendons. An unspecified Mycoplasma species was identified through broad-range bacterial PCR testing. The patient was then started on oral doxycycline which, combined with serial debridement and eventual tenolysis, resulted in successful eradication of her infection and functional improvement.

CONCLUSION

Our case highlights the power of clinical utility of broad-range bacterial PCR in detecting atypical infections; this modality should be considered in infections caused by cat scratches with otherwise negative cultures.

Utility of Routine Blood Cultures for Upper Extremity Abscesses

BACKGROUND

Patients with skin and soft tissue infections (SSTIs) are often admitted by the emergency department for intravenous antibiotic therapy and surgical drainage of abscesses if necessary. As part of the initial diagnostic workup, blood cultures are routinely drawn at our institution in patients with SSTIs. This study seeks to identify the utility of performing blood cultures in patients with upper extremity abscesses as it relates to the number of incision and drainage (I&D) procedures performed, patient readmission rates, and length of hospital stay.

METHODS

A retrospective chart review of 314 patients aged 18 to 89 years who underwent 1 or more I&D procedures of upper extremity abscesses were included in the study. Patient demographic data, comorbidities, laboratory values, wound and blood culture results, number of I&D procedures performed, length of stay, and readmission rates were evaluated.

RESULTS

Increasing age and white blood count were associated with an increased number of I&Ds performed. Obtaining blood cultures, whether positive or negative, was associated with increased length of stay. There was no association between obtaining blood cultures and number of procedures performed on multivariable analysis. Positive blood cultures were associated with increased readmission rates.

CONCLUSIONS

Routinely obtaining blood cultures in patients with upper extremity abscesses may not be beneficial. Obtaining blood cultures is not associated with an increased number of I&D procedures or readmission rates. Furthermore, obtaining blood cultures, regardless of positivity, is associated with increased lengths of hospital stay.

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.

Prospective analysis of glucose metabolism in patients with hand infection

BACKGROUND

Type-2 diabetes influences the course and severity of hand infections.

METHODS

We prospectively examined glucose metabolism in 90 patients with hand infection, distinguishing between normal, prediabetic and diabetic states. HbA1c-levels were evaluated prior to surgery. Patients with normal levels took an oral glucose tolerance test and those diagnosed with prediabetes were retested after the infection subsided. Hospital stay, number of surgical interventions and inflammatory markers were examined per group.

RESULTS

Sixty-two patients (68.8%) had abnormal glucose metabolism: 17 (18.9%) with history of diabetes and 11 (12.2%) newly diagnosed. Prediabetes was observed in 34 patients (37.8%). At follow-up, prediabetes and diabetes were diagnosed in 7 cases each, and physiological glucose metabolism was observed in 3 patients. For the 11 patients unable to undergo a second oral glucose tolerance test, detailed phone calls confirmed absence of diabetes. C-reactive protein levels were significantly elevated in diabetic patients compared to those with normal glucose metabolism (p = 0.001) or prediabetes (p = 0.034). Patients with history of diabetes were significantly older than those with normal glucose tolerance (p = 0.001) or prediabetes (p = 0.017). There were no significant intergroup differences in thrombocyte count, length of hospital stay, interval from injury to admission or the number surgical interventions.

CONCLUSION

Glucose metabolism should be assessed in patients with hand infections and reassessed after the infection has subsided in prediabetic cases.

Is tropical pus in the hand special? A retrospective study comparing hand infection cases in Darwin and Adelaide

BACKGROUND

Hand infections are a common reason for presenting to hospital and can be associated with significant morbidity and prolonged antibiotic use. Factors recognized to influence patient outcomes include resistant organisms and delayed presentation. Surgeons working around Australia may assume that hand infections and appropriate treatment algorithms will be similar between sites. This is the first study to examine differences between hand infections presenting in Darwin (with its tropical climate) vs. those in a more temperate city (Adelaide).

METHODS

This is a two-site retrospective study, where diagnostic discharge codes were used to identify cases for a 12-month period and patient age, sex and rurality, duration of hospital stay, microbiology results and subsequent trips to theatre were reviewed.

RESULTS

Despite significant differences in rurality between FMC and RDH patients, there was no significant difference in length of hospital stay, duration of intravenous antibiotics or return trips to theatre across the two sites. RDH reported a 25% rate of MRSA, compared to 18% at FMC, as well as a statistically significant increase in uncommon microbes, with 30% compared to 12% of patients growing microbes that may not be covered by antibiotics routinely administered in metropolitan areas. A limitation of this study was that compliance with antibiotics and hospital stay were not accounted for.

CONCLUSION

It is often our training years that determine our norms of everyday practice, but fewer Australian surgical training posts are located in tropical centres. The results of this study highlight the importance of not assuming that the spectrum of organisms causing hand infections are the same as that in the surgeons' state of origin.

Tenosynovitis of hand: Causes and complications

Tenosynovitis represents a common clinical condition characterized by inflammation of the synovium that encases the tendon sheath. Although tenosynovities may be noted in any tendon in the body, extremities such as hand, and foot remain the sites of high predilection to acquire this condition. The predominant cause of this predilection rests in the intricate tendon arrangements in these extremities that permit fine motor actions. This editorial explores the common causes and the complications associated with this condition to improve the understanding of the readers of this common condition encountered in our everyday clinical practice.

Implementation of full-length 16S nanopore sequencing for bacterial identification in a clinical diagnostic setting

This study describes the implementation of 16S nanopore sequencing in a diagnostic lab for pathogen identification without prior enrichment. First, the universality of the test and taxonomic resolution was evaluated for 78 clinically relevant bacteria (69 known and 9 unknown bacterial cultures). Next, the diagnostic value of the test was evaluated based on clinical samples. It was shown that 16S sequencing can be used both for identification of unknown cultures and to find bacteria directly in the clinical sample without cultivation. All culture-positive samples (n=11) tested positive with 16S sequencing directly performed on the sample, but bacteria were found as well in 15/30 culture-negative samples. Pathogenic bacteria were found in a background of commensal flora, and even complex polymicrobial infections could be unraveled. This study demonstrates the feasibility of implementing 16S nanopore sequencing in a clinical diagnostic setting and demonstrates its value for the diagnosis of culture-negative and polymicrobial infections.

Carpal tunnel syndrome

Median neuropathy at the wrist, commonly referred to as carpal tunnel syndrome (CTS), is the most common entrapment neuropathy. It is caused by chronic compression of the median nerve at the wrist within the space-limited carpal tunnel. Risk factors that contribute to the etiology of compression include female gender, obesity, work-related factors, and underlying medical conditions, such as hypothyroidism, pregnancy, and amyloidosis. The diagnosis is made on clinical grounds, although these can be confounded by anatomical variations. Electrodiagnostic studies, which are specific and sensitive in diagnosing CTS, support the diagnosis; however, a subgroup may present with normal results. The advent of imaging techniques, including ultrasound and MRI, further assists the diagnostic process. The management of CTS is divided into the nonsurgical approaches that include hand therapy, splinting and corticosteroid injection, and surgical decompression of the carpal tunnel. Although several surgical techniques have been developed, no one method is more effective than the other. Each of these management approaches are effective at providing symptom relief and are utilized at different severities of the condition. There is, however, a lack of consensus on standardized diagnostic criteria, as well as when and to whom to refer patients for surgery.

Hand infection following bloody coin game: A case report

Bloody coin is a dangerous game that is frequently played among children and is becoming increasingly widespread. In this article, we aimed to present a patient treated for a serious hand infection requiring hospitalization due to this game. A 13-year-old girl was consulted to our plastic, reconstructive and aesthetic surgery clinic with a large erythema on the dorsum of her right hand. The patient was evaluated in favor of cellulitis and clinical improvement was achieved with intravenous antibiotherapy, absolute elevation, dressing and immobilization. Bloody coin is a dangerous game threatening the health of children in our country. Appropriate measures should be taken by health and education authorities.

Is Prolonged Use of Antibiotic Prophylaxis and Postoperative Antithrombotic and Antispasmodic Treatments Necessary After Digit Replantation or Revascularization?

BACKGROUND

Ensuring the patency of repaired vessels is pivotal in improving the success rate of digit replantation. There is no consensus on how to best approach postoperative treatment for digit replantation. The influence of postoperative treatment on the risk of failure of revascularization or replantation remains unclear.

QUESTIONS/PURPOSES

(1) Is there an increased risk of postoperative infection with early discontinuation of antibiotic prophylaxis? (2) How are anxiety and depression affected by a treatment protocol consisting of prolonged antibiotic prophylaxis and administration of antithrombotic and antispasmodic drugs and by the failure of a revascularization or replantation procedure? (3) Are there differences in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins? (4) What factors are associated with failure of revascularization or replantation?

METHODS

This retrospective study was conducted between July 1, 2018, and March 31, 2022. Initially, 1045 patients were identified. One hundred two patients chose revision of amputation. In all, 556 were excluded because of contraindications. We included all patients in whom the anatomic structures of the amputated part of the digit were well preserved, and those with an ischemia time for the amputated part that did not exceed 6 hours. Patients in good health without any other serious associated injuries or systemic diseases and those without a history of smoking were eligible for inclusion. The patients underwent procedures that were performed or supervised by one of four study surgeons. Patients were treated with antibiotic prophylaxis (1 week); patients treated with antithrombotic and antispasmodic drugs were categorized into the prolonged antibiotic prophylaxis group. The remaining patients treated with antibiotic prophylaxis for less than 48 hours and no antithrombotic and no antispasmodic drugs were categorized into the nonprolonged antibiotic prophylaxis group. Postoperative follow-up was for a minimum of 1 month. Based on the inclusion criteria, 387 participants with 465 digits were selected for an analysis of postoperative infection. Twenty-five participants with a postoperative infection (six digits) and other complications (19 digits) were excluded from the next stage of the study, in which we assessed factors associated with the risk of failure of revascularization or replantation. A total of 362 participants with 440 digits were examined, including the postoperative survival rate, variation in Hospital Anxiety and Depression Scale scores, the association between the survival rate and Hospital Anxiety and Depression Scale scores, and the survival rate based on the number of anastomosed vessels. Postoperative infection was defined as swelling, erythema, pain, purulent discharge, or a positive bacterial culture result. Patients were followed for 1 month. The differences in anxiety and depression scores between the two treatment groups and the differences in anxiety and depression scores based on failure of revascularization or replantation were determined. The difference in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins was assessed. Except for statistically significant variables (injury type and procedure), we thought that the number of arteries, number of veins, Tamai level, treatment protocol, and surgeons would be important. A multivariable logistic regression analysis was used to perform an adjusted analysis of risk factors such as postoperative protocol, injury type, procedure, number of arteries, number of veins, Tamai level, and surgeon.

RESULTS

Postoperative infection did not appear to increase without prolonged use of antibiotic prophylaxis beyond 48 hours (1% [3 of 327] versus 2% [3 of 138]; OR 2.4 [95% confidence interval (CI) 0.5 to 12.0]; p = 0.37). Intervention with antithrombotic and antispasmodic therapy increased the Hospital Anxiety and Depression Scale scores for anxiety (11.2 ± 3.0 versus 6.7 ± 2.9, mean difference 4.5 [95% CI 4.0 to 5.2]; p < 0.01) and depression (7.9 ± 3.2 versus 5.2 ± 2.7, mean difference 2.7 [95% CI 2.1 to 3.4]; p < 0.01). In the analysis based on the failure of revascularization or replantation, the Hospital Anxiety and Depression Scale scores for anxiety (11.4 ± 4.4 versus 9.7 ± 3.5, mean difference 1.7 [95% CI 0.6 to 2.8]; p < 0.01) and depression (8.5 ± 4.6 versus 7.0 ± 3.1, mean difference 1.5 [95% CI 0.5 to 2.5]; p < 0.01) were higher in the failed revascularization or replantation group than in the successful revascularization or replantation group. There was no increase in the artery-related risk of failure (one versus two anastomosed arteries: 91% versus 89%, OR 1.3 [95% CI 0.6 to 2.6]; p = 0.53). For patients with anastomosed veins, a similar outcome was observed for the two vein-related risk of failure (two versus one anastomosed vein: 90% versus 89%, OR 1.0 [95% CI 0.2 to 3.8]; p = 0.95) and three vein-related risk of failure (three versus one vein anastomosed: 96% versus 89%, OR 0.4 [95% CI 0.1 to 2.4]; p = 0.29). Factors associated with failure of revascularization or replantation included the mechanism of injury (crush: OR 4.2 [95% CI 1.6 to 11.2]; p < 0.01, avulsion: OR 10.2 [95% CI 3.4 to 30.7]; p < 0.01). Revascularization had a lower risk of failure than replantation (OR 0.4 [95% CI 0.2 to 1.0]; p = 0.04). Treatment with a protocol of prolonged antibiotics, antithrombotics, and antispasmodics was not associated with a lower risk of failure (OR 1.2 [95% CI 0.6 to 2.3]; p = 0.63).

CONCLUSION

With proper wound debridement and patency of repaired vessels, prolonged use of antibiotic prophylaxis and regular antithrombotic and antispasmodic treatment may not be necessary for successful digit replantation. However, it may be associated with higher Hospital Anxiety and Depression Scale scores. Postoperative mental status is associated with digit survival. Well-repaired vessels, instead of the number of anastomosed vessels, could be critical to survival and decrease the influence of risk factors. Further research on consensus guidelines that compare postoperative treatment and the surgeon's level of expertise after digit replantation should be conducted at multiple institutions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Skin Popping for the Hand Surgeon: A Case Report and Review

INTRODUCTION

Subcutaneous injection of illicit drugs, colloquially known as skin popping, is associated with skin and soft tissue infections of the upper extremity. Sequelae of these infections often present to hand surgeons in the late stages of disease, are associated with challenging clinical scenarios, and are a significant burden to both patients and providers. The authors present an illustrative case and review the literature regarding this growing phenomenon in upper extremity surgery.

METHODS

A case report detailing the surgical reconstruction of a large forearm wound in the setting of intravenous heroin use and skin popping is presented. Search terms related to upper extremity subcutaneous drug injection were used to find relevant articles in PubMed and EMBASE. A total of 488 articles were found, with 22 studies meeting the inclusion criteria.

RESULTS

In this case report, the patient had a long history of skin popping to the forearm and presented with a chronic wound with exposed bone. The patient was treated with serial debridement, bony fixation, intravenous antibiotics, and soft tissue coverage using an arteriovenous loop and a muscle-only latissimus flap. Literature review yielded 22 studies comprising 38 patients with 55% (11/20) women and age range of 23 to 58 years. Heroin was the most commonly used drug (50.0%). The most common presentation was soft tissue infection (6/20 patients), manifestations of noninfected wounds (5/20), and wound botulism (4/20 of patients). Seventy percent of patients presented with multiple injection sites. Surgical management was described in 18% of cases, with all but one case describing drainage and debridement techniques. Only one case of formal reconstruction using a dermal template was described.

CONCLUSIONS

Skin popping infections have unique pathogenesis, presentation, and management patterns that hand surgeons must be aware of when treating these patients. A literature review revealed a relative paucity of reports regarding risk factors and surgical management of "skin popping" sequelae. If patients are reconstructive candidates, complex reconstruction requiring free tissue transfer may be warranted.

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

BACKGROUND

Hand infections are heterogeneous, and some may undergo successful outpatient management. There are no strict guidelines for determining which patients will likely require inpatient admission for successful treatment, and many patients succeed with outpatient therapy. We sought to determine risk factors for failed outpatient management of cellulitic hand infections.

METHODS

We performed a retrospective review of patients who presented to the Emergency Department (ED) for hand cellulitic infections over five years, from 2014 to 2019. Vital signs, lab markers, Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Measure (ECM), and antibiotic use were investigated. Discharge from the ED without subsequent admission was considered an outpatient success, while admission within 30 days of the prior visit was considered a failure. Continuous variables were compared with Welch's t test, and categorical data with Fisher's exact tests. Multivariable logistic regression was performed on comorbidities. Multiple testing adjustment was performed on p-values to generate q-values.

RESULTS

Outpatient management was attempted for 1,193 patients. 31 (2.6%) infections failed treatment, and 1,162 (97.4%) infections succeeded. Attempted outpatient treatment was 97.4% successful. Multivariable analysis demonstrated higher odds of failure with renal failure according to both CCI (OR 10.2, p < 0.001, q = 0.002) and ECM (OR 12.63, p = 0.003, q = 0.01) and with diabetes with complications according to the CCI (OR 18.29, p = 0.021, q = 0.032).

CONCLUSIONS

Outpatient treatment failure was higher in patients with renal failure and complicated diabetes. These patients require a high index of suspicion for outpatient failure. These comorbidities should influence consideration for inpatient therapy though most patients can undergo successful treatment as outpatients.

LEVEL OF EVIDENCE

Level III.

Neonatal Deep Palmar Space Infection: An Unusual Presentation

Deep palmar space infection is a rare but potentially serious condition in neonates that requires prompt diagnosis and management. We present the case of a neonate who developed a deep palmar space infection on day two of life. The neonate presented with swelling, erythema, tenderness, and limited movement of the affected hand. The diagnosis was confirmed with imaging using ultrasound, which revealed evidence of fluid collection suggestive of an abscess. Surgical drainage of the abscess and appropriate antibiotic therapy resulted in a successful outcome with complete resolution of symptoms and recovery of hand function. This case highlights the importance of early recognition, appropriate diagnostic workup, and prompt surgical intervention for deep palmar space infection in neonates to prevent complications and achieve favourable outcomes. Additionally, infection prevention measures such as maintaining strict aseptic techniques during invasive procedures in neonates should be emphasised to prevent similar infections in the future.

Successfully Treated Upper-Extremity Necrotizing Fasciitis Caused by Photobacterium damselae

Necrotizing fasciitis is a soft-tissue infection associated with significant morbidity and mortality. The bacteria most associated with necrotizing fasciitis include Streptococcus pyogenes (group A), Clostridium species, Streptococcus species, and Staphylococcus species. Photobacterium damselae (P. damselae), formerly known as Vibrio damselae, is a halophilic, gram-negative bacillus known to infect marine organisms in warm coastal waters. Necrotizing fasciitis associated with P. damselae has been reported to have higher rates of serious complications and mortality because of an atypical presentation and a rapidly progressive course. This report presents a case of successfully treated P. damselae necrotizing fasciitis of the upper extremity and the nuances of management that led to a favorable outcome in which the patient was discharged for home without complications.

Peripherally Inserted Central Line Catheters following Hand and Wrist Infections

Hand and wrist infections may cause varying degrees of morbidity requiring antibiotic therapy of variable duration and often operative intervention. Peripherally inserted central line catheters (PICCs) are placed when an extended course of intravenous antibiotics is anticipated. The present study aims to analyze utilization and impact of PICC placement on the management of hand, wrist, and forearm infections.

METHODS

The PearlDiver Patients Records Database was queried to identify patients who underwent treatment for infection of the hand, wrist, and forearm between 2010 and 2018. Logistic regression analysis was utilized to evaluate the association of patient-related risk factors with PICC utilization, complications, readmissions, and length of stay (LOS).

RESULTS

A total of 24,665 patients with an upper extremity infection were included in the study. Ultimately, 416 patients required a PICC placement (1.69%). Patients with older age, male gender, certain medical comorbidities, and infection involving deeper structures were more likely to require a PICC. Ninety-day all-cause medical complication rates were significantly higher for the PICC group (19.7% versus 6.7%) compared to those without. Any hospital readmission rates were significantly higher for PICC group at 90 days (28.4% versus 6.3%) and 1 year (35.8% versus 10.9%). Readmission rates remained slightly higher at 1 year for both groups. The PICC group demonstrated significantly longer LOS by 2 days (7.72 days versus 5.14 days).

CONCLUSION

While not required for the majority of hand, wrist, and forearm infections, PICC placement is associated with increased medical complications, more frequent hospital readmissions, and longer LOS.

Packing a Punch: Fight Bite Induced Septic Joint

'Fight bites' constitute a considerable number of accidental human bite injuries. Where the mechanism involves a closed fist contacting another person's teeth, the subsequent injury tends to involve the metacarpophalangeal joint region. These injuries are unique for their seemingly benign appearance on initial presentation. Their presence can easily be missed if the treating physician does not seek investigative history and a high index of suspicion. If improperly managed, fight bites may be associated with the introduction of bacteria that may invade deeper tissues, causing potential debilitation from progressive infection. Our case discusses a 33-year-old female who presented three weeks after an altercation where a fight bite occurred but was not treated with antibiotics on discharge. Her clinical presentation matched a flexor sheath infection, which was revealed after investigation to be a consequence of a septic metacarpophalangeal joint that had also progressed to involve the underlying bones. The case outlines the dangers of improper assessment and management of fight bite injuries and reviews best practices surrounding the recognition, assessment, and treatment of these patients in the Emergency Department.

Septic arthritis of the hand: Current issues of etiology, pathogenesis, diagnosis, treatment

Septic arthritis of the hand is a serious disease that often results in dysfunction of the joint or even the need to perform amputation of the finger. They rank second in the frequency of occurrence after lesions of the knee joint. Many points concerning the etiology, the timing of the development of cartilage destruction and the development of osteomyelitis, approaches to surgical treatment, the duration of antibiotic therapy, and the start of rehabilitation measures remain the subject of numerous discussions. Based on a search in the PubMed, Web of Science and Google Scholar databases down to 1990-2021, publications on septic arthritis of the hand were found and analyzed. The following inclusion criteria were used in our review: (1) Septic arthritis of the hand; (2) Published in a peer review journal; (3) Written in English; and (4) Full text version available. Studies were excluded if they met any of the following criteria: (1) Letters; (2) Articles published in abstract form only; and (3) Cadaveric studies. Septic arthritis of the hand was characterized by the most frequent damage to the joints of the index and middle fingers (> 50% of cases). Up to 90% of cases, the infection enters the joint as a result of penetrating trauma, animal bites, etc. Staphylococcus aureus became the most frequently isolated microorganism (30%-55%), and its polyantibiotic-resistant form Methicillin-resistant Staphylococcus aureus was found, according to various sources, from 0% to 73% among all isolated Staphylococcus aureus. In arthritis, Pasteurella multocida (6%-11%) is often isolated as a result of animal bites. Articular cartilage destruction in the experiment developed within 24-48 h after infection. In clinical studies, the development of osteomyelitis was noted when treatment was delayed by more than 10 d. X-ray data during the first two weeks were uninformative. Priority of surgical treatment of septic arthritis. Drainage and surgical treatment, and with the development of osteomyelitis, the implementation of arthrodesis. Antibacterial therapy for 2-4 wk and early start of rehabilitation measures. Timely surgical treatment in combination with antibiotic therapy and rehabilitation makes it possible to obtain a positive result in the treatment of septic arthritis of the hand.

Cross-Sectional Analysis of Paronychias in the National Electronic Injury Surveillance System 1999–2018

Introduction

Paronychia is the most common hand infection. Prior paronychia studies were limited by small patient numbers. We conducted a national-level analysis over two decades, analyzing demographics, etiologies, and trends in paronychia cases.

Methods

We conducted a retrospective analysis of paronychia cases in the 1999–2018 National Electronic Injury Surveillance System database. Sex, race, age, and cause were recorded and compared using χ², ANOVA, and t tests. Multivariable linear regression analysis assessed changes in age, weight, and sex over time.

Results

We analyzed a total of 2,512 cases, with an average age of 27.6 ± 20.6 years, 45.5% females, and 25.6% white and 28.6% black patients. In multivariable linear regression, both age and weight significantly increased over time. Manicuring was the most common etiology (30.9%), increasing in incidence over time and with a higher frequency in adults (p < 0.0001) and females (p < 0.0001). There was a significant decrease in pediatric paronychia cases over time, particularly in 0- to 4-year-olds. Possible limitations include missed paronychia cases or additional non-paronychia cases due to improper coding, infrequent race reporting, and inability to analyze treatments or distinguish between paronychia subtypes.

Conclusions

Paronychia cases were associated with increased age and weight over time with different presentations by age. Manicuring represents the largest growing paronychia etiology.

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.

The Effect of Acupuncture on Hand and Wrist Pain Intensity, Functional Status, and Quality of Life in Adults: A Systematic Review

Objective: This systematic review examined the effects of acupuncture on hand-and-wrist pain intensity, functional status, quality of life, and incidence of adverse effects in adults. Methods: Searches of 6 databases and previous reviews for randomized controlled trials (RCTs) were performed. Each outcome was analyzed for participant conditions, interventions, controls, and follow-up times determined a priori. Active controls were excluded. Follow-up periods were based on Cochrane 5.1.0 guidelines. The results were tabulated and described narratively. Results: In the 10 included RCTs (622 participants), 6 had a low risk of bias. For cryotherapy-induced pain, 1 trial showed significant pain reduction post treatment. For rheumatoid arthritis, 1 trial shown significant pain reduction and function improvements post treatment and short-term. For carpal tunnel syndrome, 1 trial showed significant pain reduction and functional improvements intermediate-term, while 3 trials suggested no significant difference. For tenosynovitis, 1 trial showed significant pain reduction and function improvements short-term. For poststroke impairments, 1 trial showed significant function improvements post treatment and at short-term, while another trial suggested no significant difference. No significant improvements were noted for trapezio-metacarpal joint osteoarthritis. In 2 trials, adverse effects occurred in patients with carpal tunnel syndrome; yet acupuncture appeared to be relatively safe. Conclusions: Acupuncture may be effective and safe for short-term pain reduction and functional improvement in hand-and-wrist conditions. Clinicians should interpret the results with caution due to small sample sizes and clinical heterogeneity. Future research is warranted.

Necrotizing Soft Tissue Infection of the Upper Extremity as a Manifestation of Hansen’s Disease

Hansen’s disease is a well-described, largely historic infection that is caused by Mycobacterium leprae. Lucio's phenomenon is an aggressive, rare form of untreated lepromatous leprosy characterized by diffuse cutaneous lesions and systemic symptoms. To date, cases of necrotizing soft tissue infection in the setting of leprosy have rarely been reported in the literature. We present the case of a 51-year-old man with no known past medical history who presented for the evaluation of acute-on-chronic left upper extremity ulceration, soft tissue swelling, and pain. The patient was diagnosed with necrotizing soft tissue infection of the left upper extremity and underlying multibacillary lepromatous leprosy with Lucio's phenomenon. He underwent dermatofasciectomy of the affected extremity, followed by staged soft tissue coverage, including dermal allograft placement. Proper antibiotic management was also undertaken. In this article, we describe a case of previously undiagnosed leprosy with Lucio's phenomenon manifesting as necrotizing fasciitis of the upper extremity.

Flexor Tenosynovitis Caused by Mycobacterium heraklionense

Mycobacterium heraklionense is a rare etiology of serious hand infection with only 2 cases having been reported in literature to date to our knowledge. We describe the case of a 58-year-old woman with persistent swelling and stiffness in her right index finger. Advanced imaging studies in addition to serial surgical debridement with tissue cultures helped to confirm the diagnosis of flexor tenosynovitis caused by M. heraklionense. In this case report, we highlight the clinical evaluation, operative treatment, and antimicrobial therapy leading to the successful care of this disease presentation. Due to its rarity and potential to cause substantial hand infection, M. heraklionense should be included in the differential diagnosis as the cause for chronic flexor tenosynovitis to appropriately minimize morbidity.

Treatment of hand infections using WALANT -when the anesthesiologist is not available: A retrospective cohort study

Backround

The aim of this study was to determine, if Wide Awake Local Anesthesia No Tourniquet (WALANT) can be used as an alternative method of providing anesthesia in management of deep infections of the hand. Since the advent of WALANT in 2003, infections of the hand have been regarded as a contraindication to its use. Occasional shortage of anesthesiologic manpower, especially during busy call hours and the current COVID-19 pandemic can lead to delay of treatment where urgent surgery is needed, to prevent progress of an infection, that can result in severe morbidity.

Methods

In the period from 2015 to 2020, 16 patients with various infections of the hand underwent 17 operations using WALANT in a Hand Trauma and Replantation Center (HTRC) in Germany. Retrospective cohort analysis of their operation reports, with emphasis on location of infection, time and duration of the operation, intraoperative incidents and complications were carried out. We also evaluated the need for revision surgery or necessity to convert to general anesthesia and factors causing delay till the time of surgery.

Results

No case of inadequate analgesia, the need to convert to general anesthesia, ischemic events or cardiovascular complications with the use of the WALANT solution containing adrenaline and lidocaine in the treatment of deep tissue infections.

The highest priority of limb preservation was ensured as no patient progressed to amputation of a digit or the hand. There was a statistically significant difference (p≤0.01) in delay from the time of admission until surgery of up to 9h24 m (SD±3h34 m) during the week and 4h10 m (SD±2h28 m) during the weekend.

Conclusion

The status of infection as an absolute contraindication to the use of WALANT should be revised. Especially when human resources are limited, WALANT is an adequate technique to enable quick anesthesia for urgent treatment to prevent progression of hand infections.

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Wide Awake Local Anesthesia No Tourniquet can be used to treat deep hand infections.

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In the COVID-19 pandemic alternative ways of providing anesthesia are needed.

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Absolute contraindication to the use of WALANT should be reevaluated.

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“time is function”, urgent treatment remains key in management of hand infections.

[Infections of the Hand after Bite Injuries]

Bite injuries are common. Along with the resulting complications, they represent approximately 1-2 % of all emergency department visits. In over 75 %, the hands are affected. In Northern Europe, bites and subsequent infections are mainly caused by dogs and cats but also by humans.Up to 40 % of all hand infections are caused to bite injuries. Due to the multiple and complex compartments as well as the low soft tissue coverage of functionally relevant structures, even the smallest and most superficial bite injuries of the hand lead to infections. Any bite injury to the hand may subsequently may result in a fulminant infection and, rarely, even death.The spectrum of pathogens from the oral flora of the biting animal or person is diverse and includes aerobic and anaerobic bacterial strains. Bite injuries represent a major challenge for both the injured person and the attending physician. The rate of complications has been shown to increase with delayed medical consultation, lack of medical care and inadequate wound care. In this review, we discuss the types and complications of bite wounds, their potential risk of infection, their pathogen spectrum and appearance, and their effective treatment.

[Indications for and Limits of conservative Treatment in Hand Infections]

The treatment of infections of the hand is an important part in hand surgery. Despite oft new antibiotic therapy there is a major part of surgical intervention. But there are certain cases in which a conservative treatment is indicated if a closed control is provided. Important is a careful examination, a detailed anamnesis of profession, hobby, animal or human contact, journey and secondary disease. Apart from antibiotics, limited immobilisation, physical conservation, moist dressing and pain management are important factors. In case of a conservative therapy, attention must be payed to the kind of infection and secondary diseases because there is a higher risk for complications, combined Infections and atypical pathogens in immunosuppressed patients. Typical indications for conservative treatment are erysipelas, cellulitis, early stages of felon and paronychia. Rare indications are infections with Erysipelothrix rhusiopathiae, Herpes simplex and fungal pathogens. No indications are symptoms longer than 2 days, abscess, bacterial infections of tendons, necrotizing fasciitis and empyema.

Morphological, genetic and clinical correlations in infantile hemangiomas and their mimics

Infantile hemangiomas (IHs) are the most frequent pediatric benign vascular tumors, with a reported incidence of 5% to 10%. They have self-limiting evolution pattern divided into a growth phase in the first 12 months and a regression one, that may take up to 10 years. Occasionally, hemangiomas might lead to local or systemic complications, depending on their morphological characteristics. The first line of treatment is β-blockers, such as Propranolol, Timolol, Nadolol, administered either locally or systemically. Newer therapeutic strategies involving laser therapy and angiotensin-converting enzyme inhibitors are being studied, while older treatment modalities like corticosteroids, Imiquimod, Vincristine, Bleomycin and Interferon-α have become second line therapy options. Before establishing the appropriate treatment, clinical, histological, and imaging investigations are required.

Painful nails: A practical approach to the diagnosis and management of painful nail conditions

Because several nail disorders share similar clinical features, their diagnosis and management can be challenging to clinicians. The physical examination may disclose localized abnormalities or point to an underlying systemic disease, requiring additional workup. Furthermore, cosmetic distress and nail-related symptoms (e.g., tingling, stinging, numbness, and pain) are common factors that influence the patient's search for medical assistance. Nail pain (i.e., onychalgia) can accompany both localized and systemic pathology. Onychalgia can be acute or chronic according to the time of evolution; patients may describe it as intermittent or constant, and as a throbbing, burning, sharp, or shooting sensation denoting the nature of the pain. It may be exacerbated by colder temperatures, touch, and increased activity (e.g., manipulating objects, walking). We present four main groups of conditions that might cause nail pain: nail tumors, nail deformities, inflammatory or infectious diseases, and external or traumatic agents. Our article includes an overview of the clinical features, as well as diagnosis and management pearls for each entity. Physicians (dermatologists and nondermatologists) should be aware that abnormalities of the ungual and subungual space are not exclusive of dermatological disorders but may also be present in noncutaneous contexts.

Hand infections

The hand is an extremely versatile organ adapted for fine tasks with various clinicoanatomical compartments. This article reviews the types of common hand infections that present to the emergency department and/or hand surgeon, with relevant investigations and strategies for diagnosis and treatment, with the emphasis on distinguishing between superficial and more serious infections.

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.