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134
Table 23.3 Predisposing factors for the development of gas gangrene
Factors Mechanism
Foreign body such as soil, clothing, bullets, glass pieces Soil supplies calcium and silicic acid which causes tissue necrosis
Anoxia due to crushing of the arteries Necrosis of the tissues results in proliferation of the organism
Dead and devitalised tissues Anaerobic organisms multiply
Blood clots Supplies calcium
Extravasated haemoglobin and myoglobin Cease to carry oxygen
Table 23.4 Toxins and their effects
Toxins Effects
1. Lecithinase (alphatoxin)—commonly found in • Dermonecrosis
C. perfringens type
2. Beta toxin • Necrosis of the tissues
Proteinase • Breakdown of collagen fibres
3.
Hyaluronidase • Breaks the cement substance of the muscle cells—hyaluronic acid
4.
5. Theta toxin • Vascular injury and destroy leukocytes
6. Kappa toxin • Destroy connective tissue and help speed necrosis
A strain Haemolysis
Manipal Manual of Surgery
Profound toxaemia
Risk Groups
• Patients who have had lower limb amputations
performed for ischaemic gangrene (may develop
infection from their own bowel organisms).
• High velocity gunshot wounds with perforation of a
hollow viscus (military wounds).
• Immunocompromised patients.
• Trauma is postoperative—most common form of gas
gangrene (70%).
• Patients with diabetes mellitus, blood vessel disease
(atherosclerosis), or colon cancer.
• Intravenous drug users and gas gangrene: Repeated
trauma of the needle due to intramuscular/deep
injections, anaerobic environment facilitates development of gas gangrene in these patients. Clostridia can
survive in heroin preparations.
Pathogenesis
• Gas gangrene develops in wounds that are heavily
contaminated with soil or a foreign body, or in those
associated with a laceration and devitalised muscle
mass. This type of situation is common following road
traffic accidents. Endogenous infection from the
patient’s faecal matter may be responsible for gas
gangrene in certain cases of contamination of a
surgical wound caused by below knee amputation
done for some other cause.
• All these factors contribute to create low oxygen
tension. Under these favourable conditions,
clostridial organisms multiply and produce toxins
Section II • General Surgery
that cause further tissue damage (Table 23.4).
• Once powerful toxins start acting, various patho-
logical events, such as inflammation, oedema, muscle
necrosis, and gangrene of the muscles, set in (Fig. 23.2).
• Features of SIRS (systemic inflammatory response
syndrome) are present.
Refer to Key Box 23.2.
Key Box 23.2
Why Gas Gangrene Spreads Fast?
Massive infection
Gross injury
Devitalised tissue
Poor immunity
Foreign body
Clinical Features (Table 23.5)
• Severe pain in the limb, swelling, fever, and toxicity.
• In untreated cases, the necrotic process continues and
septicaemia, renal failure, peripheral circulatory failure,
and death occur. Foamy liver is the condition wherein
gas is produced in the liver as a part of septicaemia.
Systemic Complications
• Liver necrosis—jaundice
• Haemolytic anaemia
• Renal failure
Diagnosis
• In addition to clinical suspicion, an easy method of
confirming the diagnosis is to examine the pus under
microscopy after Giemsa staining.
• These organisms are gram-positive and spore-bearing.
Tetanus and Gas Gangrene
135
Fig. 23.2: Pathological changes
Table 23.5 Clinical features
Local features General features
Severe pain and gross oedema of the wound Anxious and alert
Sutured wound is under tension Toxic and ill
Thin brownish fluid escapes which has sickly sweet odour Rapid increase in the pulse rate
Palpable crepitus Hypotension due to suppression of adrenals
Colour changes in the muscles Vomiting
Skin becomes khaki-coloured due to haemolysis Low grade fever
• Lecithinase test or Nagler’s reaction: Many species of
Clostridium produce lecithinase (C. baratti, C. absonum,
C. bifermantans, C. sordelli, and C. novyi). But the alpha
(α) toxin of C. perfringens has phospholipase activity.
Table 23.6
Clostridial Nonclostridial
myonecrosis necrotising
It neutralises the Lecithin C activity which forms
the basis for Nagler’s reaction.
• X-rays, computerized tomography (CT) scans and
magnetic resonance imaging (MRI) scans: Will reveal
gas and extent of tissue damage.
A few differences between clostridial myonecrosis
and non-clostridial necrotising infections are given in
Table 23.6.
• Exudate Thin Dishwater initially
• Erythema Absent Present—mild
• Muscle gangrene Present Absent
• Toxicity Very rapid Rapid
• Bullae Haemorrhagic Nonhaemorrhagic
• White blood cells Absent Present
in the discharge
infections
purulent later
Section II • General Surgery
136
Manipal Manual of Surgery
Prophylaxis
As gas gangrene is highly fatal, it is better to prevent its
development by observing the following principles
during wound management:
1. Debridement: All dead muscles, necrotic tissues, bone
pieces, and foreign material should be removed. Pus
should be evacuated. Wound should be thoroughly
irrigated with antiseptic agents.
2. Prophylactic antibiotics: Penicillin is the drug of
choice. Injection crystalline penicillin 10–20 lakh units
4–6th hourly should be given for 7 days.
3. Judicious and minimal use of tourniquets: If possible,
tourniquets should be avoided while managing such
a wound in the leg.
4. Gentle but effective application of plaster cast with
or without treatment of associated fractures to avoid
compressing the blood vessel.
When in doubt, do not suture the wound.
Treatment of Established Gas Gangrene
(Summary—Key Box 23.3)
Key Box 23.3
Summary of Gas Gangrene
Correct hypotension
Control infection
Treat dehydration
Early debridement
Administer hyperbaric oxygen
Give blood transfusion
Passive immunisation
To save life, amputate
Principles of the treatment
The triad of gas gangrene treatment principles are:
Antibiotics, debridement and hyperbaric oxygen
therapy. Other treatment includes supportive treatment.
1. Antibiotics should be continued: Injection crystalline
penicillin 10–20 lakh units 4–6th hourly should be
given for 7 days. Systemic Inflammatory Response
Syndrome (SIRS) can be caused by Clostridium
septicum. It is treated by clindamycin 600–900 mg
Fig. 23.3: Gas gangrene
8th hourly, vancomycin 1 g 12th hourly, or
metronidazole 500 mg 8th hourly.
2. Surgery: Emergency surgery with excision of all dead
muscles and necrotic tissues by using generous, long
incisions. This is called debridement. This is the most
important part of the treatment. However, when
patient is severely ill with hypotension and shock,
only life saving measure is amputation.
3. Hyperbaric oxygen therapy: It will reduce the
amount of toxin produced by the organisms.
Patient
is asked to lie down in a chamber and pressure inside
the chamber will slowly rise to about 2.5 times normal
atmospheric pressure.
Supportive Treatment
• Blood transfusions before, during and after surgery.
• Polyvalent anti-gas gangrene serum.
A 40-year-old gentleman presented to the hospital with
massive gas gangrene involving his right upper limb,
chest wall, abdominal wall, and back (Fig. 23.3). It started
after an injury to his right elbow. The patient had initially
received treatment at a local hospital. Due to lack of
proper facilities, he was neither subjected to any surgical
procedure nor given any resuscitation. When he came to
our hospital, he was in septic shock.
It was too late when we saw the patient. He had severe
hypotension and renal failure. Emergency resuscitation
and debridement was done. However, within six hours of
admission, he expired.
Section II • General Surgery
Tetanus and Gas Gangrene
137
1. Which of the following statements regarding tetanus
is false?
A. Exotoxins are produced by Clostridium tetani
. The toxin gets fixed to motor cells of anterior horn
B
cells
C. It stimulates the release of cholinesterase
D. The period of onset is more important than the
incubation period
2. Favourable conditions for the development of tetanus
include all of the following except:
A. Injury B. Foreign body
. Devitalised tissues D. Aerobic conditions
C
3. Hyperbaric oxygen may be used in all of the following
conditions except:
A. Gas gangrene
B. Decompression sickness
C. Carbon monoxide poisoning
D. Necrotising fasciitis
4. The following facts are true regarding gas gangrene
except:
A. It is caused by Clostridium welchii
. Severe myonecrosis is a feature
B
C. Brownish fluid has a foul odour
D. Alpha toxin causes cell membrane damage
5. Positive Nagler reaction in gas gangrene is caused by:
A. Lecithinase B. Beta toxin
. Proteinase D. Hyaluronidase
C
6. Sponge-like consistency of the part is typically seen
in which condition?
A. Necrotising fasciitis B. Diabetic leg ulcer
C
. Gas gangrene D. Pyomyositis
7. The following are true regarding Clostridium welchii
except:
A. Anaerobic B. Gram-positive
. Nonspore-bearing D. Produces toxins
C
8. The following are clinical features of gas gangrene
except:
A. Crepitus B. Khaki coloured skin
C. Low grade fever D. Hypertension
9. The following are features of necrotising fasciitis
type II except:
A. It is monomicrobial—β-haemolytic streptococci
It may also occur in young and healthy individuals
B.
C. Organism is Clostridium perfringens
D. It may give rise to toxic shock syndrome
10. Which of the following is false regarding gas
gangrene prevention?
A. Antigas gangrene for risk groups
B
. Prophylactic antibiotics
C. Blood sugar level should be maintained within
200 mg/dl
D. Avoid tourniquets while operating on crushed
wounds in the legs
Answers
1. C 2. D 3. D 4. C 5. A 6. C 7. C 8. D 9. C 10. C
Section II • General Surgery
24
Hand, Foot Infections and Tendon Transfer
Paronychia
Subcutaneous infections
Acute lymphangitis of hand
Terminal pulp space infections
Apical subungual infection
Web space infections
SU6.1: Define and describe the aetiology and patho-
genesis of surgical infections.
INTRODUCTION
Hand infections are commonly encountered in manual
labourers and are precipitated by injury, such as a thorn
prick, cut injuries, etc. In 80–90% of cases, the causative
organism is Staphylococcus aureus sensitive to cloxacillin.
In the remaining cases, streptococci, gram-negative
bacilli, or anaerobic organisms may play a role.
Irrespective of the site of infection, oedema is commonly
present on the dorsal aspect because of the following
reasons:
• Lymphatics from the palmar aspect of the hand travel
through the dorsal aspect to the corresponding lymph
node.
• Presence of loose areolar tissue in the dorsum of the
hand.
Hand infections may be severe in immunocompro-
–
mised, systemically ill, and diabetic patients. It
may spread rapidly and cause septicaemia and death.
– It is unfortunate that in cases of gas gangrene and
spreading infections, amputation may have to be done.
Oedema is the chief cause of stiffness of the fingers. Hence,
early physiotherapy should be encouraged.
Deep palmar abscess
Acute suppurative tenosynovitis
Mycetoma pedis
Ingrowing toenail
Tendon transfer
Classification of Hand Infections (Table 24.1)
Table 24.1 Classification of hand infections
Superficial infections Deep infections
1.Paronychia 1.Terminal pulp space infection
2.Subcutaneous infections 2.Apical subungual infection
3.Infection of dorsal space 3.Volar space infection
4.Acute lymphangitis 4.Web space infection
5.Midpalmar space infection
6.Tenosynovitis
SUPERFICIAL INFECTIONS
PARONYCHIA
1
It refers to infection near the nail. It is the most common
type of hand infection. There are two types—acute and
chronic.
Acute Paronychia (Fig. 24.1)
• It occurs due to trimming of the nail or an ingrowing
nail.
• Subcuticular infection starts in the lateral sulcus and
spreads all around (paronychia means ‘run around’).
This is because the eponychium (skin overlying the
nail base) is adherent to the nail base. Hence, the
infection spreads beneath the nail base. The affected
finger is painful. Throbbing pain suggests the pre-
1
Paronychia—infection affects the base of nail.
138
Hand, Foot Infections and Tendon Transfer
Fig. 24.1: Acute paronychia—very painful condition, can be
treated very easily
139
sence of pus. Even collection of 0.5 ml of pus produces
severe pain. Low grade fever may be present.
Treatment
• Early cases (before the formation of pus) may be
managed by soaking, elevation, antibiotics, and
immobilisation.
• After a digital block (with 5 ml of 2% plain lignocaine
injected into the root of the digit), incision and
drainage is done by incising the eponychium.
Adrenaline should not be used for infiltration in the
finger, penis, or ear lobule as these areas are supplied
by end-arteries (no collateral circulation). Adrenaline
is a vasoconstrictor and may cause gangrene. Pus is
sent for culture and sensitivity. Antibiotics are given.
Dressings are applied.
Chronic Paronychia
1
• It is not due to bacterial infection, but due to fungal
infection—moniliasis/Candida.
• It is common in women who wash clothes, utensils,
etc. and constantly have wet fingers. As a result of
this, fungal infection takes place. The infection is
insidious in onset, chronic, and difficult to eradicate.
It produces a dull nagging pain in the fingers. The
eponychium is faintly pink and the nail is ridged.
• Antifungal agents such as nystatin or tolnaftate
solution help the patient. Rubber gloves should be
worn while using hands for washing.
SUBCUTAENOUS INFECTIONS (Figs 24.2–24.4)
1. Intraepidermal abscess (purulent blister): Cuts,
pricks, and burns may cause this condition.
2. Intradermal abscess: This variety does not produce
a dome-shaped elevation.
3. Subcutaneous abscess: This type of lesion is like that
of cellulitis.
Figs 24.2 to 24.4: Intraepidermal abscess, intradermal abscess
and subcutaneous abscess respectively Fig. 24.4: Collar-stud
abscess also
4. Collar-stud abscess: It results when the epidermal
component is connected to the dermal component.
Treatment
Incision and drainage under an antibiotic cover. Care
should be taken to drain the deeper cavity.
ACUTE LYMPHANGITIS OF THE HAND
• It is caused by an injury, which may be a minor
abrasion.
• The causative organism is Streptococcus.
Clinical Features
• Severe pain in the hand with fever, chills, and
rigors.
• Gross oedema of dorsum of the hand.
• Red, hot streaks over the limb which indicate the
route of lymphatics.
• Regional lymph nodes are swollen and tender.
Infection of little finger—epitrochlear nodes are
–
enlarged.
– Infection of ring and middle fingers—supraclavi-
cular nodes are enlarged.
– Infection of index and thumb fingers—axillary
nodes are enlarged.
Treatment
• Injection crystalline penicillin 10 lakh units IV or IM
for 5–7 days.
• Higher antibiotics may have to be used, depending
on the response.
1
Wet nails of women who wash dishes are vulnerable.
Section II • General Surgery
140
Manipal Manual of Surgery
HERPETIC WHITLOW
• It is due to herpes simplex virus (HSV).
• Common in children, may follow herpetic gingivo-
stomatitis.
• Most common viral infection of the hand—distal
finger.
• Pain, pruritus, and vesicles are characteristics. Fever
and lymphadenitis are present.
• It resolves spontaneously.
• The diagnosis is mainly clinical. However, culturing
the virus from the vesicular fluid, assessing immunofluorescent serum antibody titres, or performing a
Tzanck smear may confirm the diagnosis.
• Antivirals such as acyclovir or famciclovir are of some
benefit if started within 48 hours.
DEEP INFECTIONS
INFECTION OF THE TERMINAL PULP SPACE (FELON)
This space commonly gets infected due to relatively
deep prick injuries. It is the second most common
infection of the hand, seen in about 25% of patients.
Clinical Features (Key Box 24.1)
• Injury to the affected finger is usually present. Thumb
and index fingers are commonly involved.
• Throbbing pain is worse in the dependent position,
with nocturnal exacerbations.
• An indurated, red, and tense pulp space is charac-
teristic of this condition.
• Touch and movement worsen the pain.
Key Box 24.1
Terminal Pulp Space Infection—Felon
Fingertip pulp abscess
Extremely painful
Loss of normal resilience of pulp
Osteomyelitis of distal phalanx in untreated cases due
to thrombosis of digital artery
No longer recommended fish mouth incision
Remember as FELON
Treatment
Incision and drainage under digital block—volar
longitudinal incision.
Anatomy of the Terminal Pulp Space
• It is a closed space, formed by the fusion of the distal
flexion skin crease and the deep fascia attached to
the periosteum of the distal phalanx, just distal to the
insertion of flexor digitorum profundus. Each pulp
space is subdivided by the presence of numerous
septa which pass from the deep fascia to the
periosteum. Thus, 15–20 small compartments are
formed (Fig. 24.5).
• The digital artery, which is an end-artery, runs in
this closed space (Fig. 24.6).
Complications
1. If the pus is not released early, thrombosis of the digital
artery takes place, resulting in osteomyelitis and necrosis
of the terminal phalanx, which may result in shortening
of the finger (Fig. 24.7).
. Pyogenic arthritis of the distal interphalangeal joints.
2
3. Tenosynovitis secondary to pus, which requires
regular physiotherapy to avoid the development of
thickness.
4. Neuroma, which may be painful and cause discomfort.
Section II • General Surgery
Fig. 24.5: Felon
Fig. 24.6: Pulp space infection
Fig. 24.7: Plain radiography of
hand showing osteomyelitis of
terminal phalanx
Hand, Foot Infections and Tendon Transfer
141
APICAL SUBUNGUAL INFECTION
• Infection is confined to the space
between the distal quarter of the
subungual epithelium and the
periosteum of the distal phalanx.
Penetration by a sharp object
causes this condition. It often
manifests as a tender yellow spot
beneath the distal portion of the
nail. Pain, redness, and minimal
swelling are the features.
• Tenderness is maximum at the
free edge of the nail. The pulp and
distal parts of the fingers are
relatively painless. It is treated by
a “V” excision of a portion of the
nail to open the abscess cavity
under an antibiotic cover (Fig. 2
4.8).
Fig. 24.8: “V” exci-
sion of the nail, for
apical infection
MIDDLE AND PROXIMAL VOLAR
ACE INFECTIONS (Fig. 24.9)
SP
• These spaces are loose in comparison to the terminal
pulp spaces. They are filled with fibrofatty tissue.
• The middle volar space is closed, but proximally
communicates with web space.
• The swelling is tender and indurated. The finger is
held in flexion.
• It is treated by a transverse incision and drainage of
the pus.
Key Box 24.2
Web Space Infections
3 web spaces
Finger separation sign
Gross oedema of dorsum
Spread to other web space
Fig. 24.10: Three web spaces
Causes of Web Space Infection
• Penetrating injuries
• Spread of a proximal volar space (palmar space)
infection.
• Lumbrical canal infection—suppurating tenosynovitis.
WEB SPACE INFECTIONS (Key Box 24.2)
Web spaces are the triangular spaces between the four
divisions of the palmar aponeurosis. There are 3 in
number (Fig. 24.10). The thumb has no palmar aponeurosis. They are filled with subcutaneous fat and are
covered posteriorly by the metacarpal bones.
Fig. 24.9: Middle and proximal volar space infections
Clinical Features
• Pain and swelling of the palm in the region of the
web space.
• Extremely tender and hot swelling.
• Finger separation sign: Adjacent fingers are separated
due to oedema.
• Gross oedema of the dorsum of the hand.
• If untreated, pus from one web space may spread to
other web spaces and/or to the proximal volar space.
Treatment
Under anaesthesia, a transverse skin incision is made and
the pus is drained (Fig. 24.11). The cavity is treated like
any other abscess cavity. The skin edge is trimmed to leave
a diamond-shaped opening behind for better drainage.
MIDPALMAR SPACE INFECTION/DEEP PALMAR ABSCESS
• Infection of the midpalmar space results in a deep
palmar abscess.
• The midpalmar space is the space behind the palmar
aponeurosis and in front of the metacarpal bones.
Section II • General Surgery
142
Fig. 24.11: Drainage of web space abscess
Manipal Manual of Surgery
• Since the palmar fascia is thick, strong, and un-
yielding, pus collects deep to the palmar fascia. If it
is due to penetrating injuries, it collects in the subcutaneous plane like a collar-stud abscess. In the
centre of the palm, there is no subcutaneous tissue.
Hence, pus collects beneath the thick dermis.
Surgical Anatomy of the Palmar Fascia
and Aponeurosis (Fig. 24.12)
• The central, thick, fibrous part of the palmar fascia is
the palmar aponeurosis.
• The palmar fascia covers the long flexors.
• The apex of the triangular palmar aponeurosis is
continuous with the flexor retinaculum and the
palmaris longus tendon.
• Distally, it forms 4 longitudinal digital bands that
attach to the bases of the proximal phalanges.
• Two (medial and lateral) fibrous septa extend from
the medial and lateral margins of the palmar
aponeurosis. The septa are attached to 5th and 3rd
metacarpals, respectively.
• Deep to the flexor tendons, digital arteries and nerves
lie in the midpalmar space.
• The midpalmar space is continuous with the anterior
compartment of the forearm via the carpal tunnel.
This space is called the ‘space of Parona’ (Fig. 24.13).
Source of Infection
• Penetrating injuries
• Haematoma
• Suppurative tenosynovitis
Clinical Features
• Obliteration of the normal concavity of the palm
• Gross oedema of the dorsum of the hand
• Extreme tenderness in the midpalmar space
• Fingers are held in flexion at the metacarpophalangeal
(MP) joint because the palmar aponeurosis gets
relaxed in this position. MP joint movements are painful.
• IP (interphalangeal) joint movements are not
painful.
Thus, swollen palm, oedema of the dorsum of the hand, flexed
attitude of the MP joint, and separated fingers give the picture
of a frog hand.
Section II • General Surgery
Fig. 24.12: Cross-section showing deep palmar space
Fig. 24.13: Space of Parona and its relationship to other structures
Hand, Foot Infections and Tendon Transfer
143
Treatment
• Under anaesthesia, a transverse crease incision is
made until the palmar aponeurosis is seen, which is
split longitudinally in the direction of the fibres to avoid
damage to the nerves and vessels.
• The abscess cavity is treated as per the usual manner.
ACUTE SUPPURATIVE TENOSYNOVITIS
1
Surgical Anatomy of the Flexor Tendon Sheath
Arrangements (Fig. 24.14)
• The flexor tendon sheaths which enclose the tendons
run along the entire length of the finger. In the palm,
the medial tendons are enclosed by a common
synovial pocket called the “ulnar bursa,” whereas the
lateral tendons are enclosed by the “radial bursa.”
• These two bursae communicate in 75% of the cases.
In 25% of the cases, the flexor tendon sheath of the
thumb communicates with the radial bursa, and that
of the little finger communicates with the ulnar bursa.
• Thus, infection flexor tendon sheaths may involve the
entire hand.
• The flexor tendons sheaths extend from the base of
the terminal phalanges to the heads of the metacarpal
bones.
Clinical Features (Key Box 24.3, Figs 24.15 and 24.16)
• The patient gives a history of a pricking injury.
• Symmetrical, fusiform, painful enlargement of the
fingers.
• Fixed, flexed fingers—‘Hook sign’
• IP joint movements are very painful: Severe pain on
passive finger extension.
Key Box 24.3
Suppurating Tenosynovitis
Sharp prick injuries
Hook sign—bent finger
IP joint movements painful
MP joint movements need not be painful
‘Kanavel’s sign’
Fig. 24.15: Suppurative teno-
synovitis
Fig. 24.16: Grossly swollen
hand in a diabetic patient. It
was looking dangerous, but
responded to conservative line
of treatment
• MP joint movements are not painful: This sign
differentiates suppurating tenosynovitis from a deep
palmar abscess.
• Similarly, when there is infection of the radial bursa,
there is tenderness over the lateral side, over the
flexor pollicis longus sheath.
Kanavel’s Four Cardinal Signs of Flexor Tenosynovitis
1. The finger is held in flexion because this increases
. Symmetrical fusiform swelling of the entire finger.
2
3. Passive extension of the affected digit produces
4. Maximum tenderness is at the proximal cul-de-sac
Treatment
• Under anaesthesia, multiple incisions may have to
Fig. 24.14: Flexor tendon sheath arrangements
1
Henry Hamilton Bailey lost his left index finger because of acute tenosynovitis.
• The cavity is irrigated with antiseptic solution.
the volume of the synovial sheath and eases pain.
exquisite pain.
of the synovial sheath of the index, middle, and ring
fingers in the distal palm.
be given to decompress the flexor tendon sheaths to
relieve tension and drain the pus, exudate, etc.
Section II • General Surgery