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chapter
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27
WEB SPACE INFECTION
(COLLAR-BUTTON ABSCESS) AND
PALMAR SPACE INFECTIONS
The hand has several “deep spaces” that can allow for spread of
infection and confinement within a discrete area. The concepts of
the ulnar and radial bursae are addressed in Chapter 25. Web space
infections that develop between the digits and can spread into the
palm are discussed here.
Mechanism of Injury
l These can originate from puncture wounds, blisters, psoriatic
lesions, or callouses.
l The infection spreads dorsally and palmarly in the web space
and can spread through palmar spaces.
l Inquire about history of wounds, exposure to infection, fever,
chills, or other systemic symptoms.
l Inspect for swelling, erythema, and wounds; digits might be
“held apart” by web space infection (Figure 27-1).
l Palpate for tenderness, fluctuant areas, and lymphadenopathy.
l Relevant laboratory studies: order CBC with differential, ESR,
and CRP. If patient febrile, blood cultures should be sent.
l Radiographs can be used to assess for radiopaque foreign body
or fracture (often confused with infection in diabetic patients).
Evaluation
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126 Chapter 27
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Figure 27-1. This patient developed a web space infection
around his ring finger likely related to his psoriatic lesions. The
puncture wounds were self-inflicted to “drain the pressure”
when the purulence started tracking distally into the digit. For
a full-color version, see page CA-III of the Color Atlas.
Acute Treatment
l Provide pain management. Splint for comfort with a volar plas-
ter splint and elevate the hand.
l Keep patient NPO for possible surgery.
l Consult hand surgeon immediately for consideration of surgical
incision and drainage (I&D).
l Do not administer antibiotics prior to adequate intraoperative
culture; this can invalidate culture results and complicate the
treatment course.
Definitive Treatment (Refer to Hand Specialist)
l Surgical I&D with or without catheter irrigation is likely.
l The required antibiotic course can range from days to weeks.
l Inadequate treatment (surgically or pharmacologically) can lead
to continued or spread of infection, resulting in stiffness, deformity, and loss of function.
Potential Problems
Web Space Infection and Palmar Space Infections 127
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SUGGESTED READING
Abrams RA, Botte MJ. Hand infections: treatment recommendations for specific
types. J Am Acad Orthop Surg. 199 6 ; 4 ( 4 ) : 219 -230.
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chapter
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28
CELLULITIS
Cellulitis is a bacterial infection of the skin which, if left untreated,
can result in spread of infection, formation of abscess (or infectious
tenosynovitis), or other serious consequences. In general, this can be
managed nonoperatively if caught before any collections develop. An
important differential diagnosis is necrotizing fasciitis, which is a
limb- and potentially life-threatening surgical emergency.
Mechanism of Injury
l The patient might recall a puncture wound, insect bite, or
scratch on digit or extremity.
l Superficial skin infection can spread proximally up the arm.
l Determine patient and environmental risk factors (diabetic,
exposure to organisms, history of trauma in affected area).
l Assess erythema, swelling, warmth, and tenderness of skin and
subcutaneous tissues (Figure 28-1).
l Must differentiate from septic joint; cellulitis is painful superfi-
cially, not necessarily with joint motion. Must also differentiate
from necrotizing fasciitis, which is very painful, rapidly progressive, and usually associated with more systemic symptoms
(acute illness is much more “impressive” than the early skin
changes).
l Identify any skin lesions from which infection might have
originated.
Evaluation
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130 Chapter 28
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Figure 28-1. This patient developed painful erythema without
inciting event. He was admitted to the hospital and the cellulitis
resolved with empiric IV antibiotic treatment, splinting, and elevation. For a full-color version, see page CA-III of the Color Atlas.
l Assess for red “streaking” up arm due to lymphangitis and
adenopathy, indicative of potential systemic spreading.
l Assess radiographs for free air from Clostridium infection.
l Labs: CBC looking for an elevated WBC, glucose (diabetic?),
ESR, CRP to monitor infection.
l If febrile or systemically ill, obtain blood cultures to determine
bacteremia.
Acute Treatment
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Cellulitis 131
Figure 28-2. “Strict eleva-
tion” is accomplished by
using a stockinette gently
looped around the splint and
attached to an IV pole or ceiling fixture (as shown). Placing
the hand on a pillow generally
is too short term and rarely
creates enough elevation.
l Have a low threshold for admitting patient to hospital for obser-
vation.
l Start empiric IV antibiotics: ampicillin/sulbactam is usually the
first-line intravenous agent.
l Splint hand/wrist in neutral position for comfort and elevate
from IV pole or ceiling fixture (Figure 28-2).
l Consult hand surgeon if there is a question of abscess, infec-
tious tenosynovitis, septic joint, or necrotizing fasciitis.
Definitive Treatment (Refer to Hand Specialist)
l Cellulitis is treated nonoperatively, but hand surgeons will dif-
ferentiate cellulitis from an abscess, septic joint, purulent flexor
tenosynovitis, or other surgical emergencies.
132 Chapter 28
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Potential Problems
l Infection can spread locally or systemically.
l Soft tissue damage might lead to stiffness or other loss of func-
tion.
SUGGESTED READING
Abrams RA, Botte MJ. Hand infections: treatment recommendations for specific
types. J Am Acad Orthop Surg. 199 6 ; 4 ( 4 ) : 219 -230.
chapter
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29
HERPETIC WHITLOW
Herpetic whitlow has an annual incidence of 2.5 to 5 cases per
100,000 people. This condition generally resolves spontaneously, but
misdiagnosis as a paronychial infection with subsequent incision
can lead to bacterial infection or viral spread. Consider this before
incising a paronychial infection, especially in a health care worker or
immunocompromised patient.
Mechanism of Injury
l Patient is inoculated with herpes simplex virus (HSV) 1 or 2 in
an area of broken skin.
l Health care workers or others exposed to oral or genital herpes
are at risk.
l Identify any risk factors (occupational or other exposure).
l Assess for erythema, edema, or tenderness; these lesions often
are quite painful. Early stages can show the clear vesicles of
HSV 1 or 2, while later stages can look like a bacterial infection.
l Evaluate patient for fever or lymphadenopathy.
l Tzanck test, viral culture, or DNA testing can confirm diagno-
sis.
Evaluation
133
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