Transcript Pains In Joints During Pregnancy

HAND INFECTIONS
Col. T.L.B. le Roux
Maj. A.J. Julyan
Department of Orthopeadic Surgery
1 Military Hospital
2012
From : The Hand Book (Chapter 5)
INTRODUCTION
 One
of the most serious hand injuries
 Most important cause of hand swelling
 Neglect > involvement rest of hand
 Adhesions + loss of vital structures
 Loss of function
 Amputation (Partial > total)
MANAGEMENT
 Correct
and early diagnosis
 Correct, early and aggressive surgical and
medical management
 Early mobilization and rehabilitation
PATHOPHYSIOLOGY
 Organisms
via various routes
 Direct penetration, haematogenous,
anatomical tissue planes
 Local tissue reaction and oedema
 Tissue tension > impaired circulation
 Microvascular thrombosis and ischemia
 Abscess formation
AIM OF TREATMENT
 Preserve
good circulation
 Arrest microbial proliferation
PRINCIPLES OF TREATMENT
 Early
decongestion by abscess drainage
 Appropriate dressing to allow draining
 Splinting of the hand in the correct
physiological (functional) position
 Elevation to reduce swelling
 Appropriate antibiotics when applicable
 Hand baths
 Early mobilization and rehabilitation
BACTERIOLOGY
 Most
common : Staphylococcus aureus
 Other 50% : Streptococci, Gram negative
organisms, fungi, TB
SYMPTOMS + SIGNS
 Hallmarks
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Throbbing pain
Raised local skin temperature
Redness
Tenderness
Swelling
 Severity


of inflammation:
and expressiveness:
Type of injury
Type of organism
SPECIAL INVESTIGATIONS
clinical judgement – most important
 X – rays : osteitis or septic arthritis
 Bacteriological studies
 Sound


Mixed, chronic infections
Extraordinary ( TB, Fungal )
 Histology
 Serology
: Gonococcus, Syphilis, Brucella
 Biochem : Gout
DIFFERENTIAL DIAGNOSIS
 Aseptic

inflammatory conditions
Gout, OA, De Quervain’s, non-infectious
tenosynovitis
 Allergic
conditions
 Peripheral vascular disease, peripheral
nerve disease, diabetes mellitus

Poor blood supply, slower healing, resistant to
antibiotics
 Insect
bites
TREATMENT - Anaesthesia
 Necessary
for thorough debridement and
wound toilet
 Children : General anaesthetic
 Adults : General or regional ( brachial
plexus, axillary, subacromial )
Treatment – Bloodless field
 Mandatory
the hand for 30 – 60 seconds
 Dangerous to use Eschmarch or other
kind of bandage to accomplish a bloodless
field
 The septic process could be squeezed
proximally
 Elevate
Treatment - Incision
Treatment - Dressings
 Plugs
should never be used
 One layer of paraffin gauze – packed with
loose gauze swabs
 Dressings removed within 24 hours
 Followed by hand baths
 Avoid Eusol and Saline > tissue damage
 Rather Plasmalyte B, Ringers
Treatment - Dressings
Treatment - Debridement
 Drained
abscess – cleaned out – tip of
finger
 Soft tissue adhering – must be removed
 Prevents chronic discharge
Treatment - Splinting

Splint the postoperated hand in a functional
position
 Reduces the swelling, relaxation of lymphatics
and veins
 Alleviates pain
 Functional (Physiological) position
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Wrist in 30 degrees of dorsiflexion
MP joints in 90 degrees of flexion
Interphalangeal joints in full extension
First webspace in full abduction and extension of the
first metacarpal (open)
Treatment – Hand baths
 Very
important for mechanical cleaning
 Large bowl with lukewarm water and soap
 Patient cleans with his other hand
 Closed with dressing afterwards
 Repeated 3-4 times daily
 Use Hibidil or Savlon
 Start immediate hand therapy after
dressings
Treatment - Swelling
mobilization – reducing swelling –
regaining full function
 Not later than 12 – 24 hours after surgery
 Enemy of the hand is oedema
 It inevitably leads to fibrosis and stiffness
 Elevate above the level of the hart
 Early
Treatment – Antibiotics
general not necessary – source
removed
 Take swabs with initial debridement
 If any doubt exists – appropriate A/B
 Also indicated in early stages of infection
 When pus collection is evident the
treatment is surgical drainage not A/B
 In
Treatment – Analgesics
 These
are painful conditions!
 Effective pain relief – enhances early
mobilization
 Be aggressive and break the pain cycle
 Combination of Opiate, NSAID, Sedative
 Most also available IVI
Complications
 Chronicity

Diabetes, Gout, peripheral vascular disease
 Persistent

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
drainage
Incomplete drainage, foreign bodies, osteitis
and soft tissue sequestrum
Leads to persistent drainage
Initial debridement shouldn’t leave behind any
devitalized, dead or foreign tissue
Complications
Complications
 Joint


stiffness
Delayed onset of mobilization
Incorrect dressings, pain, oedema
 Spreading
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Delayed treatment
 Gas
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infection
gangrene
Farm or outdoor related injury
Aggressive debridement, rinsing and A/B
SPECIAL INFECTIONS
 Streptococcal
 Human
infections
bites
 Osteitis
 Septic
arthritis
 Lymphangitis
 Necrotizing fasciitis
 Pyogenic Granuloma
SPECIAL INFECTIONS
 Postoperative
wound infection
 Burns
 Paronychia
and eponychia
 Felon or pulp space infection
 Palmar space infections
 Septic tenosynovitis
 Leprosy, TB, Mycobacterium Marinum
 Dorsum hand and others
Streptococcal infections
 Rapidly
spreading cellulitis without
abscess formation
 Epithelium is elevated by a collection of
serous fluid – blister
 Treatment :
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Remove elevated epithelium
Paraffin gauze
Appropriate A/B
Streptococcal infections
Human Bites
 Most
septic and most serious bite
 Mixed flora – extremely pathogenic to
normal tissue
 Tips of fingers, knuckles
 “ Fight bite” –
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Attacker with finger in full flexion
Presents as patient fingers in extension
Superficial puncture wound
Much deeper into MP joints – “closing off “
Human bites
aggressive – debridement wide
and with fingers in flexion and extension
 A/B : Triple therapy – Penicillin,
Aminoglycoside, Metronidazole
 Can still cause osteitis
 Sometimes partial amputation only way to
stop spread of infection
 Treatment
DOGBITE
DOGBITE
Septic Arthritis
 Should
be distinguished from gouty
arthritis
 Arthrotomy and debridement
 Synovectomy and irrigation
 Appropriate A/B
 Joint mobilization
Lymphangitis
 Red
streak on the dorsum of hand or volar
aspect of forearm
 Streptococcal origin
 Elevation
 Splintage
 IVI Penicillin
Necrotizing Fasciitis
organism : Clostridia family –
mostly Perfringens
 Sometimes Streptococci
 Overwhelming, fast spreading, with
systemic toxic symptoms
 Radical surgical debridement and redebridement
 IVI A/B : Start on high doses Penicillin
 Causitive
Pyogenic Granuloma
“
Proud flesh “
 Overgrowth of granulation tissue
 Chemical cauterization :


Silver Nitrate
Iodine
 Surgical
removal and skin grafting
 Send for histology
Pyogenic Granuloma
Postoperative Wound Infection
 Prevention

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Aseptic techniques
Gentle tissue handling
Preservation of blood flow
Prevention of oedema
 Treatment
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
:
:
Removal of sutures
Hand baths
A/B
Paronychia
Early stages –
elevation and A/B
 Collection of pus
– drained
 Remove lateral
aspect of nail –
can form
sequestrum
 Osteitis

Eponychium

Infection of the nail
fold in the Lunula
region
 Elevated part of nail
to be removed by two
lateral incisions
 Chronic – Candida or
Monilia
Pulp space infection (Felon)

Detrimental to blood
supply
 Osteomyelitis
Felon
Palmar space infections
Palmar Space Infections
 Webspace,
 Cause

:
Septic callus, septic blister, tenosynovitis,
direct inoculation
 Treatment
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thenar or midpalmar
:
Approach webspaces directly
Blunt dissection
Evacuate the abscess
Septic Tenosynovitis
 Serious
infection
 Massive oedema of finger
 May spread via synovial sheaths
 Kanavel’s four cardinal signs
 Early incision and irrigation
 Hand is elevated
 Mobilization is delayed for 3-4 days
Kanavel’s four signs

Slight flexion of finger
 Swelling
 Pinpoint tenderness
over sheath
 Pain on passive
extension
Septic Tenosynovitis
Septic Tenosynovitis
Leprosy
 Staged
and rare infection
 Inflammatory stage – leads to an
absolutely stiff hand
 High doses Cortisone
 Loss of sensation – burns and injuries
 Osteomyelitis can follow
 Drugs : Dapsone, Rifampicin, Clofazimine
Tuberculosis
 Not
uncommon in the wrist joint
 Diagnosis difficult
 Mostly confirmed with synovial biopsy
 Treatment :
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Synovectomy
Splintage
Rehabilitation
Drug regime
Miscellaneous
 Mycobacterium


Fishermen, spreads rapidly
Surgery , Rifampicin
 Dorsum

Marinum
hand infections
Whitlow
 Fungus

Palm trees, Bougainvillea
 Erysipelas
CONCLUSION
 Serious
conditions
 Treat timeously and with respect
 Permanent complications – huge impact
on life, work and limb
 Treat or refer as emergencies
THANK YOU