Drainage of Pus in the Hand

Hand infections are an important source of patient morbidity. They cause an enormous loss of time from work and can produce permanent deficits in hand function.42

Until recently, the availability of more prompt medical care and the administration of antibiotics had caused a dramatic decrease in the incidence of major hand infections; however, the intravenous and subcutaneous use of narcotics among drug addicts has increased, reintroducing serious hand infections to the field of surgery.

The keys to the surgical treatment of hand infections are as follows:

1. Accurate localization of the infection. Each particular infection has characteristic physical signs, according to the anatomy of the particular compartment that is infected.

2. Timing of the operation. The timing of surgical drainage is critical to the outcome of surgical treatment. If an infection is incised too early, the surgeon may incise an area of cellulitis and actually cause the infection to spread. In contrast, if pus is left in the hand too long, particularly around the tendon, it may induce irreversible changes in the structures it surrounds.

The correct timing for a given surgical procedure is difficult to determine. In the body, the cardinal physical sign of an abscess is the presence of a fluctuant mass within an area of inflammation; however, because there often is only a small amount of pus present in the hand, an abscess there can be hard to find. In addition, pus frequently is found in tissues that contain fat. At body temperature, fat itself is fluctuant, further complicating the physical diagnosis of an abscess. Nevertheless, some guidelines for the detection of pus do exist:

1. Pus may be seen subcutaneously.

2. The longer an infection has been present, the more likely it is that pus will be present. Infections of less than 24 hours’ duration are unlikely to have developed pus.

3. Classically, if the patient cannot sleep at night because of pain in the hand, pus probably has formed.

4. If slight passive extension of the finger produces pain along the finger and in the palm, the tendon sheath is likely to be infected; it should be explored to drain the pus.

The last guideline, signs of tendon sheath infection, is one of the four cardinal signs of acute suppurative tenosynovitis described by Kanavel.43

The other three follow below:

1. Swelling around the tendon sheath

2. Tenderness to palpation

3. Flexion deformity of the affected finger

Despite these guidelines, it still may be difficult to determine whether there is pus in the hand. If doubt exists, elevate the arm and treat the patient with intravenous antibiotics and warm soaks, reexamining him or her at frequent intervals. If signs of inflammation diminish rapidly, avoid surgery.

Optimum Operative Conditions

1. Use a general anesthetic or a distal nerve block. Injecting a local anesthetic at the site of infection is ineffective and actually may spread the infection within fascial planes.

2. Use a tourniquet. The arm should not be exsanguinated with a bandage, to avoid spreading the infection by mechanical compression. The arm should be elevated for 3 minutes before the tourniquet is applied.

3. Perfect lighting is critical for all explorations of pus in the hand. All relevant neurovascular bundles must be identified to ensure their preservation.

4. Draining abscesses of the hand is not like draining abscesses anywhere else in the body. Boldly incising an abscess space without approaching it carefully is to be condemned.

5. Leave all wounds open after incision.

6. Immobilize the hand in the functional position after surgery by applying a dorsal or volar splint, or both, with the metacarpophalangeal joints at 80 degrees of flexion and the proximal and distal interphalangeal joints at 10 degrees of flexion. At this position, the collateral ligaments of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints are at their maximum length and will not develop contractures during immobilization.

7. Elevate the arm postoperatively. Continue administering intravenous antibiotics until signs of inflammation begin to diminish. Mobilize the affected part as soon as signs of inflammation subside. Begin extensive rehabilitation, which may last several months.

Of the eight major infection sites listed below, the first three are seen most

often:

1. Paronychia

2. Pulp space (felon)

3. Web space

4. Tendon sheath

5. Deep palmar area

   1. Lateral space (thenar space)

   2. Medial space (midpalmar space)

6. Radial bursa

7. Ulnar bursa

8. Osteomyelitis, pyarthrosis

Surgical approaches to each of these areas are discussed below.

Drainage of Paronychia

Paronychia is infection of a nail fold. Perhaps the most common hand infection, it is caused most often by Staphylococcus aureus. It occurs in individuals from all walks of life.1 Hairdressers often are affected because hair from their clients may become embedded between the cuticle and the bony nail. Tearing the cuticle to remove a “hangnail” probably is the most common cause of this infection.

It usually is easy to see where the pus distends the cuticle. The paronychia may occur on either side or it may lift the whole of the cuticle upward. It even may extend underneath the nail.

Position of the Patient

Place the patient supine on the operating table, with the arm extended on an arm board (see Fig. 5-15).

Figure 5-73 A–D: Incisions for the evacuation of pus at the base of the nail (paronychia).

Incision

Make a short, longitudinal incision at one or both corners of the nail fold (Fig. 5-73A).

Internervous Plane

There is no internervous plane involved. The nerve supply of the skin in this region is derived from cutaneous nerves that overlap one another considerably. No area of skin becomes denervated.

Superficial Surgical Dissection

Raise the skin flap outlined by the skin incision at the base of the nail, evacuating the pus between the cuticle and the nail. If pus extends under the nail, excise either one corner of the base of the nail or half of the nail itself, depending on how it has been undermined and lifted off the nail bed (see Fig. 5-73B,C). Occasionally, a nick into the soft tissue cuticle parallel with the nail will release the pus (see Fig. 5-73D).

Dang

If the nail bed is damaged, the new nail will develop a ridge, which is a minor but permanent cosmetic deformity.

How to Enlarge the Approach

The approach cannot be extended usefully by either local or extensile measures.