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K. Hand and Foot
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C hapter Outline
·
Hand
·
Hand Infections
·
Acute Paronychia
·
Chronic Paronychia
·
Apical Subungual
Infection
·
Terminal Pulp Space
Infection (Felon)
·
Infection of Web Spaces
·
Deep Palmar Space
Infection
·
Space of Parona Infection
·
Acute Suppurative
Tenosynovitis
·
Compound Palmar
Ganglion
HAND
Surgical Anatomy of the Hand
Flexor Retinaculum
It extends medially from pisiform and hook of hamate, later-
ally to scaphoid tubercle and trapezium crest as a strong
fibrous band so as to bridge carpus to create a carpal tunnel.
Ulnar nerve and vessels, palmar cutaneous branches of
median and ulnar nerves, palmaris longus muscle are superficial to the carpal tunnel.
Median nerve, tendons of flexor digitorum superficialis,
profundus and pollicis longus, radial and ulnar bursa are
deep to flexor retinaculum.
·
Hand Injuries
·
Dupuytren’s Contracture
·
Volkmann’s Ischaemic
Contracture
·
Syndactyly
·
Foot
·
Callosity
·
Corn
·
Plantar Fasciitis
(Policeman’s Heel)
·
Ingrowing Toe Nail
(Onychocryptosis)
·
Athlete's Foot
·
Hallux Valgus
Deep palmar arch is formed by radial artery and is completed
by deep branch of ulnar artery. It gives three palmar metacarpal arteries which communicate with superficial palmar
arch. It also gives communicating, perforating branches to
dorsal metacarpal arteries.
Muscles of the Hand
Thenar muscles: Abductor pollicis brevis, flexor pollicis
brevis, opponens pollicis and adductor pollicis.
Hypothenar muscles: Palmaris brevis, abductor digiti minimi,
flexor digiti minimi and opponens digiti minimi.
Lumbricals are four in number—named from lateral to
medial.
Four palmar interossei.
Four dorsal interossei.
Nerve Supply
Abductor pollicis brevis, flexor pollicis brevis, opponens
pollicis and 1st and 2nd lumbricals are supplied by median
nerve (5 muscles).
Rest of the muscles in hand are supplied by ulnar nerve (15
muscles).
(Tendon ones)
Zone I: From the fingertip up to the attachment of flexor
digitorum superficialis (middle of middle phalanx). It contains
tendon of flexor digitorum profundus.
Zone II: It begins proximal to metacarpophalangeal joint at
distal palmar crease and extends up to the attachment of
Palmar Aponeurosis
It is a thickened, modified deep fascia in the palm with its apex
pointing proximally (as continuation of palmaris longus) and
base distally which in turn gets divided into four parts. They
extend over deep transverse ligament into lumbrical tunnel.
Blood Supply of the Hand
Superficial palmar arch is mainly formed by ulnar artery and
completed by superficial palmar branch of radial artery. It
gives four digital branches to medial three fingers.
A B
Figs. 1.256A and B: (A) Anatomy of flexor retinaculum and palmar
aponeurosis; (B) Modified Verdan zone system in the hand.
flexor digitorum superficialis at the middle of the middle
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phalanx. It is called as “No-Man’s-Land.” Here flexors are
tightly enclosed within a fibro-osseous tunnel. It is the most
dangerous zone in hand injuries (critical zone).
Zone III: It begins at the distal end of flexor retinaculum (base
of the palm) and ends at the transverse crease of the palm. It
contains lumbricals attached to flexor digitorum profundus.
Zone IV: It begins at the proximal end of the flexor reti-
naculum and ends at its distal end.
Zone V: It extends from the proximal end of flexor retinaculum
up to distal third of the forearm.
HAND INFECTIONS
Hand is a compact actively functioning unit. It contains neuro-
vascular bundles, muscles, bones and ligaments.
Infection may be due to minor injuries or blood borne.
Fig. 1.257: Infection of finger at middle phalanx level. Note the
oedema and position of the finger.
Precipitating causes: Diabetes; Immunosuppression;
Trauma; HIV infection; Steroid therapy; Vascular diseases.
COMMON ORGANISMS
B
x Staphylococcus aureus—most common—90%
x Streptococcus
x Gram-negative organisms like E. coli, Klebsiella, Pseudomonas
x Occasionally fungal infection causing chronic paronychia, Madura
hand due to Nocardia group of fungi, viral infection like orf can
occur
General Features of Hand Infection
Infection spreads faster in all areas.
Causes oedema over the dorsum of hand due to lax skin and
more lymphatic network even though infection per se is more
over the volar aspect. It looks like frog hand.
Restricted movements of fingers and hand. The hand func-
tions like hook, pinch, grip, grasp are lost.
Severe pain and tenderness, with fever.
Tender palpable axillary lymph nodes are often present.
Investigations: Pus for culture and sensitivity; Blood sugar;
Urine sugar and ketone bodies; X-ray of the part; Arterial
Doppler of the hand if needed.
DIFFERENT TYPES OF HAND INFECTIONS
B
x Acute paronychia
x Chronic paronychia
x Terminal pulp space infection (felon)
x Subungual infection
x Web space infection
x Mid-palmar space infection
x Thenar space infection
x Deep palmar abscess
x Acute suppurative tenosynovitis
x Chronic tenosynovitis of flexor tendon sheath of palm and
forearm—compound palmar ganglion
x Lymphangitis of the hand
x Arthritis of hand joints
x Subcuticular abscess
Hand infection can be superficial or deep; it can be localised or
spreading.
General Principles of Managing
Infections
Hand
Antibiotic therapy.
Position of rest with wrist slightly abducted and extended,
thumb and index fingers away (glass-holding position).
Position of function is in which thumb and index fingers are
pinching firmly with wrist extension.
Elevation of hand reduces the oedema, increases perfusion,
promotes healing.
Early recognition of localised pus. Once localised, Incision
and Drainage is done ideally under general anaesthesia or
regional block (not local anaesthe sia). Draining incision
should not cross the palmar crease. Incision should have
adequate length and adequate depth (deep to palmar fascia,
otherwise evacuation of pus is inadequate). Care should be
taken not to injure neurovascular bundles. Pus should be
sent for culture and sensitivity. Slough, if present should be
excised thoroughly. Gauze drain is placed. Regular dressings
are done with conti nuation of antibiotics. Communi cations
into other areas of hand should also be drained.
Bloodless field (using tourniquet) is better to drain pus
from hand.
Proper measures must be taken after treatment. Initial rest,
elevation of hand and later proper physiotherapy and regular
exercise of hand and fingers are encouraged to restore normal
function.
COMPLICATIONS OF HAND INFECTIONS
B
x Stiffness of digits and hand (ankylosis)
x Deformity and disability
x Bacteraemia and septicaemia
x Osteomyelitis of bones depending on the location of abscess like
metacarpal bones, terminal phalanx
x Suppurative arthritis of joints
x Paralysis of median nerve
147
CHAPTER 1K General Surgery: Hand and Foot
An ounce of action is worth a ton of theory.
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A B
SRB's Manual of Surgery
C D E
Figs. 1.258A to F: Different types of hand infections. Note the oedema of hand even on dorsal aspect. Small infective focus can aggravate
rapidly and so early proper drainage from deeper plane is important in managing the hand infections. Often it may cause extensive destruction
exposing the tendons.
REMEMBER
B
x Hand should be flexible and strong; sensitive and pain free and
coordinated to show all fine and powerful functions
x Pinch (picking a small object); power grip (holding a hammer);
key grip (holding a key); chuck grip (holding a pen); hook grip
(carrying a bag)—are the functions of hand
x Hand should be properly examined clinically for tendon functions;
neurological problems—sensations (sweat test, two point
discrimination test); for circulation (Allen’s test); joint movements;
examination of entire upper limb; opposite hand; axillary lymph
nodes and other relevant systemic examinations
F
Contd...
x Nerve conduction studies; electrophysiology; MRI hand;
radioisotope bone scan; selective angiograms; X-ray hand are
the relevant investigations other than systemic investigations
x Principles of treatment—elevation to reduce oedema; splintage
to prevent contracture; early movements once inflammation
subsides; early exploration of wound or surgical drainage
of infective area; regional anaesthesia; usage of tourniquet;
incisions when done across the flexor creases, should be at
45° angle
Contd...
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CHAPTER 1K General Surgery: Hand and Foot
Fig. 1.259: Hand positions.
A
B
Figs. 1.260A and B: Hand positions in immobilisation and function.
Fig. 1.263: Hypertrophic scar and keloid in hand and
forearm after burn contracture.
ACUTE PARONYCHIA
It is the most common hand infection.
It occurs in subcuticular area under the eponychium.
Minor injury to finger is the common cause.
Suppuration occurs very rapidly.
It tracks around the skin margin and spreads under the nail
causing hang nail or floating nail.
Organisms are Staphylococcus aureus and Streptococcus
pyogenes.
Quantity of pus is very less around 0.5 mL but it should be
drained to relieve sympotoms.
Features and Management
Severe throbbing pain and tenderness (dependent throbbing)
with visible pus under the nail root. Nail on touch is very
tender (paronychia means “Run around”).
Pus is sent for culture and sensitivity.
Antibiotics like cloxacillin, amoxicillin; Analgesics.
The pus is drained by making an incision over the eponychium.
Digital block using xylocaine 2% plain (without adrenaline as
end artery supply to digits can develop arterospasm) is given
as anaesthesia.
Fig. 1.261: Hand infection. Infection of ring finger
extending into the palm.
Fig. 1.262: Infection of little finger with dorsal oedema.
A
B
Figs. 1.264A and B: Pointing pus in acute paronychia. Quantity of
pus is very less usually around 0.5 mL.
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A
SRB's Manual of Surgery
B
Figs. 1.265A and B: Paronychia showing pointing pus in one picture
and sloughed area granulating in another picture.
If there is a floating nail, then the nail is dead and it has to
be removed.
Recovery is fast.
CHRONIC PARONYCHIA
It is commonly due to fungal infection—due to candida infection commonly.
Features and Management
Drainage with ‘V’ incision over the summit is the treatment
along with antibiotics.
Osteomyelitis is not common.
Fig. 1.266: Apical subungual infection and pus formation. Note the
‘V’ shaped incision to drain the same.
TERMINAL PULP SPACE INFECTION (FELON)
It is the second most common hand infection (25%).
Index and thumb are commonly affected.
Usually by a minor injury like finger prick.
SURGICAL ANATOMY
B
x Terminal pulp space contains fat and is partitioned by septae
which is attached from periosteum of terminal phalanx to skin
x Proximally deep fascia is attached to the periosteum distal to the
base of terminal phalanx, i.e. distal to the attachment of flexor
tendon
x So, terminal space is a closed compartment, as the result of
which pressure increases when there is infection, compressing
terminal artery leading to thrombosis, resulting in osteomyelitis
of terminal phalanx
It is common in females.
Nail is diseased with ridges and pigmentation.
Itching in the nail bed; Recurrent pain, discharge
Secondary bacterial infection may supervene.
Investigation: Culture of scrapings for fungus and other
causative agents.
Treatment:
¾
Long-term antifungal therapy—local and systemic.
¾
Antibiotics for secondary infection.
¾
In severe cases removal of nail is required.
APICAL SUBUNGUAL INFECTION
It is infection of the space between subungual epithelium
and the periosteum.
It occurs after minor trauma or rarely after formation of
subungual haematoma.
Beneath the free edge of the nail, pus comes to the surface.
Excruciating tenderness with small visible pus under the tip
(summit) of the nail is the feature.
Bacteria: Staphylococcus—most common; Streptococcus,
Gram-negative organisms.
Features
Pain, tenderness, swelling in the terminal phalanx.
Fever, tender axillary lymph nodes.
Often suppuration is severe, forming collar stud abscess
which eventually may burst.
CAUSES OF COLLAR-STUD ABSCESS
B
x Tuberculous cold abscess
x Terminal pulp space infection (Felon)
x Deep palmar space infection
Investigations: X-ray of the part is required often to rule
out osteomyelitis of terminal phalanx; Pus for culture and
sensitivity to be sent.
Treatment:
¾
Antibiotics and analgesics are started.
A B C
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Figs. 1.267A to C: (A) Anatomy of the terminal pulp space; (B) Pulp
space infection; (C) Incision for pulp space drainage.
¾
Drainage of terminal pulp space by an oblique deep incision.
¾
If there is osteomyelitis of the terminal phalanx, it has to
be amputated.
Complications:
¾
Osteomyelitis of the terminal phalanx.
¾
Pyogenic arthritis of distal interphalangeal joint and
tenosynovitis of flexor sheath.
¾
Septicaemia—in immunosuppressed individuals.
Pus is drained and sent for culture and sensitivity. If other
web spaces are involved they should be drained through
a separate incision. Edges of the wound are cut to leave a
diamond shaped opening in front. Often counter-incision
over dorsal skin of web is needed.
Fig. 1.268: Incision for web space drainage.
DEEP PALMAR SPACE INFECTION
Surgical Anatomy
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CHAPTER 1K General Surgery: Hand and Foot
INFECTION OF WEB SPACES
Surgical Anatomy
There are three triangular web spaces filled with fat between the
dorsal and volar skin. When the space is filled with pus it straddles the deep transverse ligament. Even though pus is volar, it
points out dorsally.
Infection of originates from:
x Abrasion; Callosities; Trauma.
x Infection of proximal volar space of finger.
x Infection of proximal spaces.
x Spread from other palmar spaces and from flexor sheaths
through lumbrical canal.
Bacteria: Staphylococcus, Streptococcus, Gram-negative
organisms.
Features and management:
¾
Fever; Pain and tenderness.
¾
Oedema of dorsum of hand.
¾
Maximum tenderness is on the volar aspect.
¾
separation of fingers.
¾
If untreated, infection may spread into other web spaces
and hand spaces.
¾
Elevation of hand.
¾
Antibiotics and analgesics.
¾
Drainage under regional or general anaesthesia. A horizontal incision is placed on volar skin of the web and deep-
ened to reach the space by dividing fibres of palmar fascia.
Two deep palmar spaces are present
1.
Midpalmar space.
Thenar space.
2.
Midpalmar space is bound in front by palmar aponeurosis,
behind by medial three metacarpals, laterally by a vertical line from
lateral margin of the middle finger. It contains flexor tendons, neurovas
cular bundles and lumbricals. It is the common site of the infection.
Thenar space is located anterior to lateral two metacarpals. Infection
here is usually due to extension from midpalmar space.
Midpalmar Space Infection
Causes
¾
Trauma.
¾
Spread from infection of finger spaces and web spaces.
¾
Haematogenous spread.
¾
Spread from tenosynovitis.
Features
¾
Pain and tenderness in the palm.
¾
Oedema of dorsum of hand (frog hand).
¾
Loss of concavity of palm.
¾
Painful movement of metacarpophalangeal joint (but
interphalangeal joint movements are normal and painfree).
¾
Fever.
¾
Palpable tender axillary lymph nodes.
¾
Eventually pus may come out of palmar aponeurosis
forming collar stud abscess and later sinus formation.
¾
X-ray of the part is required.
Treatment:
¾
Elevation of the affected limb.
-
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SRB's Manual of Surgery
A
Fig. 1.270: Incisions to drain midpalmar space infection.
COMPLICATIONS
B
x Osteomyelitis of metacarpals
x Stiffness of hand
B
x Suppurative arthritis
x Extension of infection into other spaces
C
Figs. 1.269A to C: Anatomy of palmar spaces of the hand and forearm.
Midpalmar space is on the medial aspect; thenar space is on the lateral
aspect. Space of Parona is on the lower forearm.
¾
Antibiotics and analgesics.
¾
Drainage: It is drained under regional/general anaes-
thesia by placing horizontal/oblique incision parallel to
the palmar crease. One should avoid crossing the crease
line as much as possible. Palmar aponeurosis is carefully
incised vertically to avoid injury of the neurovascular
bundles. Alternatively one of the interdigital web spaces is
incised horizontally; lumbrical canal (3rd or 4th) is opened
to reach the deep palmar space. Pus is drained and sent
for culture and sensitivity. Thorough saline irrigation is
very essential. Drain is placed through the wound.
Thenar Space Infection
Thenar space (triangular shape) is located anterior to the lateral two
metacarpals and fascia over transverse head of adductor pollicis;
behind the short muscles of thumb, flexor tendons of index finger
and 1st and 2nd lumbricals. Thenar muscles and flexor pollicis longus
are lateral to it; fibrous vertical septum from palmar aponeurosis
to 3rd metacarpal bone is medial to it. It is on the outer half of the
hollow of the palm. Proximally it extends from flexor retinaculum;
distally it extends to transverse palmar crease. It communicates to
fascial sheath of 1st lumbrical. It is often associated with midpalmar
space infection.
Fig. 1.271: Incision and drainage of thenar space abscess.
It is drained similarly by placing incision on the lateral aspect
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of the palm or through the first web space incision is done
along the first lumbrical canal on the radial side of the index
finger. Often incision is made parallel to cleft between index
and thumb on the posterior aspect.
In some patients, thenar space infection may spread distally
to the first web and then dorsally over the first dorsal interosseous muscle, referred to as a pantaloon abscess. In such
situation an additional counter incision over the dorsal aspect
of the hand is needed while draining.
Features
Symmetrical swelling of entire finger.
Flexion of finger—Hook sign.
Severe pain on extension.
Tenderness over the sheath.
Oedema of whole hand, both palm and dorsum (due to
lymphatic spread).
As ulnar bursa extends into the little finger its infection results
in pain and tenderness extending up to little finger but not
much to other fingers.
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CHAPTER 1K General Surgery: Hand and Foot
SPACE OF PARONA INFECTION
Forearm space of Parona is a rectangular space situated in the
lower part of the forearm above the wrist, in front of pronator
quadrates and deep to long flexor tendons. Above it extends up to
oblique origin of flexor digitorum superficialis, below up to flexor
retinaculum communicating with midpalmar space. Flexor tendon
sheath proximally extends into this space. Pus in this space is
drained through lateral incisions in the lower part of the forearm.
It is the bacterial infection of flexor tendon sheaths.
Surgical Anatomy
x Radial bursa is synovial sheath of flexor tendon of thumb which
extends to the digit.
x Ulnar bursa is synovial sheaths of medial four flexor tendons
of hand which extends into the digit of the fifth (little) finger.
B
x Swollen finger held in flexion
x Exquisite pain on passive extension
x Tenderness precisely over the tendon sheath
x Area of greatest tenderness over the part of ulnar bursa lying
between transverse palmar creases
In infection of radial bursa thumb is swollen with pain and
tenderness over the sheath of the flexor pollicis longus and
there is inextensibility of interphalangeal joint.
Swelling just above the flexor retinaculum is common.
A
Fig. 1.272: Bursae hand.
x Extensor tendons are devoid of sheaths.
x Radial and ulnar bursa communicate with each other in 80%
of cases.
Common bacteria: Staphylococcus aureus, Strepto coccus
pyogenes.
When a hand is seriously inamed it takes up the position of greatest ease, which is, in fact, the position of rest.—Frederic Wood Jone
B
Figs. 1.273A and B: Suppurative tenosynovitis is drained through
incision at proximal part and another at digital sheath. Often by placing
fine polythene catheter into the sheath, saline wash is given into the area.
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Treatment:
¾
Elevation of the affected limb.
¾
Antibiotics and analgesics.
¾
Position of rest.
¾
Drainage under general anaesthesia. Incisions are placed
over the site of maximum tenderness and flexor sheath
should be opened up. Many a times multiple incisions
are required.
It is drained through two incisions—one over the proximal part
of the sheath; other over the distal part of the sheath in the
digit—along the crease lines. A fine catheter is passed into the
sheath from proximal incision and irrigated with normal saline
SRB's Manual of Surgery
through this catheter. This catheter is left in situ for further
regular irrigations, splinting of hand is necessary with boxing
glove dressing.
COMPLICATIONS
B
x Spread of infection proximally into forearm—to space of Parona
x Stiffness of fingers and hand
x Suppurative arthritis
x Osteomyelitis
x Median nerve palsy
x Bacteraemia and septicaemia
virus infection. Contracted via direct contact with infected sheep or goats
or fomites with orf virus. Human-to-human transmission is not known. It
causes a purulent-appearing papule locally and generally without systemic
symptoms. Infected locations can include the finger, hand, arm, face and
even the penis. It may become progressive and life-threatening in immunocompromised host.
Treatment—1% cidofovir in progressive disease.
MILKER’S NODES/NODULES (Milkmaid Blisters): It is cutaneous condition
caused by Paravaccinia virus; transmitted from udders of infected cows.
Disease in humans is nearly identical to orf. Usually has got self-limiting
course, running from 14–72 days, with infrequent systemic symptoms and
little or no scarring.
HAND INJURIES
CLASSIFICATION
B
x Tidy injuries: They are clean incised wounds and are usually
treated by primary suturing but depends on the tissues involved
like nerves, tendons and muscles.
x Untidy injuries: They are lacerated wounds. Treated by debride-
ment and later by delayed primary or secondary suturing.
x Compartment injuries.
x Degloving injuries
x Indetermined injuries which could not be assessed.
COMPOUND PALMAR GANGLION
It is chronic tenosynovitis of flexor tendon sheaths due to
tuberculosis (tuberculous tenosynovitis) or rheumatoid arthritis.
It can be unilateral or bilateral.
Flexor tendon sheath on either side of the wrist is involved,
i.e. both in the volar surface of palm and lower forearm.
Swelling contains fluid with typical melon seed bodies.
Condition is often bilateral in case of rheumatoid arthritis.
Swelling in the palm and lower forearm which is smooth, soft,
nontender, fluctuant and also cross-fluctuant across flexor
retinaculum, nontransillu minating.
Wasting of hand and forearm muscles are seen.
Matted axillary lymph nodes may be palpable.
Primary focus may be present in lungs.
Investigations:
¾
ESR, chest X-ray, MRI hand.
¾
FNAC of axillary lymph node and swelling itself.
Treatment:
¾
Start antituberculous drugs: INH, rifampicin, ethambutol
and pyrazinamide for 9 months.
¾
Excision of flexor tendon sheath is done along with
scraping of caseating material, tubercles, melon seed
bodies.
¾
Care should be taken not to injure median and ulnar
nerves.
Assessment of Injury
It should include: Number, extent, depth, deformity and disability, neurovascular injuries, tendon injuries, muscle injuries
bone and joint injuries.
Principles of Treatment
Haemostasis; Use of tourniquet.
Wound debridement and cleaning.
Antibiotics and antitetanus treatment (toxoid and antitetanus
globulin).
Note:
ORF: It is a rare, benign, self-limiting exanthematous disease, also known
as contagious pustular dermatitis or infectious labial dermatitis or ecthyma
contagiosum or thistle disease or scabby mouth caused by a parapox
A
Figs. 1.274A and B: Indeterminate and untidy hand injuries.
B
Skin grafting or flaps for skin loss.
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Tendon suturing or tendon graft for tendon injuries.
Rest and elevation of the affected parts.
Management of fractures by splint, wiring.
Nerve repair for nerve injuries.
Immobilisation up to 21 days.
Later physiotherapy with warm, exercise, was bath active
movements.
Microsurgical restoration of digits. Reimplantation of the digits.
Amputation of digits or metacarpals only when inevitable.
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CHAPTER 1K General Surgery: Hand and Foot
Fig. 1.275: Hand injury exposing tendons. Note the marker stitch in
the tendon. It needs local transposition flap or groin flap to cover. Skin
grafting is not possible over tendons.
Fig. 1.276: Stuck finger by a ring. It is removed by applying soap, fat,
and wax. String method is winding and unwinding a thread under and
across the stuck finger. Sawing is done only when every method fails.
Primary repair of tendons and nerves are of lesser priority in
untidy injuries. Priority is wound debridement/wound excision and early skin cover. Cut ends of nerves and tendons are
tagged with coloured stitches for future identification purpose.
COMPLICATIONS AND MORBIDITY OF HAND INJURIES
B
x Infection; Osteomyelitis
x Arthritis of joints; Stiffness
x Loss of function due to disability
Fig. 1.277: Avulsion injury of finger causing raw area.
Primary suturing if it is a incised wound or delayed primary
suturing if there is oedema.
Fig. 1.278: Hand injury which is healing but with
severe deformity of fingers.
Fig. 1.279:
Typical deformity of finger which needs
correction for proper function.
Disease is the fate of poor, but also punishment of rich.— Ivo Andrick
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