Hand examination and hand infection
Hand:
Mechanical device with receptors can produce powerful delicate and fine
movements. The requirement for the hand function:
1. Good skin coverage with intact sensation.
2. Supple joints and mobile fingers.
3. Pain free movements and with good tendon excursion.
History:
The patient age, hand dominance, occupation and history of prior upper
extremities problem are obtained.
For traumatic injury: The time, mechanism and circumstances (e.g. work
related, contamination) of injury are obtained. Also should know the
position of the limb during injury (e.g. fall on outstretched hand, hand open
or grasping).
For nontrumatic conditions: Detail about onset and course, whether there is
impairment in sensation, or loss of function, also ask about pain and
swelling.
Physical examination:
Look:
Skin: For any cuts, haematoma, swelling, bruise, nail,also look for tight
Bands in palm leading up to fingers (duputyren contracture).
Soft tissues: Check for thenar and hypothenar wasting also check for
Wasting in cleft between fingers dorsally (damage to
Ulnar nerve or T1).
Bone: Look for swan neck deformity (have extension in middle IP joint
With flexion of distal IP joint).
Look for Boutonniere deformity (have extension at distal IP joint
With flexion at middle IP joint).
Also look for Heberden nodule over the DIP joint dorsally which
Associated with osteoarthritis.
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Feel:
Skin: feel for loss sensation or altered sensation by (cotton wick, pin
Test) along median, ulnar, radial nerve distribution.
Soft tissues: check for capillary filling in the fingers and check both
Radial and ulnar pulses. Also feel for wasting of first
Dorsal interosseous on radial side of the first
Metacarpal.
Bone: feel for any swelling, tenderness.
Move:
Active: test roll up of fingers from full extension to full flexion, test
Flexion of MCP joint in isolation while keeping PIP joint and
DIP joint extended.this test patient ability to intrinsic muscles
Movement. Also test abduction and adduction of fingers.
Passive: Passively move the joints to see the range of movement,
Pain in movement, and unstable joints.
Investigation:
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Plain x-ray
E.M.G
Ultrasound
Angiography
M.R.I
CT\SCAN
General management:
Trauma
Infection →swelling→ligament adhesion and→loss of function
Surgery
contracture
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To avoid this we should do:
1. Elevation of hand above the level of the heart so encouraging venous
and lymphatic return and thus prevented swelling.
2. Splintage-posture: when we need to immobilize hand it should be
putting in (safe position) this keep ligament under maximum stretch to
prevent their shortening and subsequent restriction of joint mobility.
Safe position: IPjoint extension, MCP joint flexion and palmer
abduction of thumb and slight wrist extension.
3. movement and rehabilitation :should done for non injured
Finger from time of injury and for injured fingers as soon as
The splint is removed.
Specific infection:
1. Cellulitis: all hand infection begins as celulitis, a superficial process
that presented with pain and, swelling and erythema.it may lead to
lymphangitis and may occasionally lymphadenopathy occur. The vast
majority of cases will respond to oral antibiotics, rest, warm soaks and
elevation.
Because gram positive organism are typically responsible, first generation
cephalosporin or pencillin is appropriate.
2. Acute paronychia: this is the most common infection of the hand, is
infection of the soft tissues alongside the nail plate. this is typically result
from inoculation of bacterium between the nail and surrounding tissues,
often as consequence of relative minor trauma such as nail biting, puncture
wound, foreign body.
S.aureus is the most common isolate, but anaerobes are frequently present
and attributed to contamination of the wound with oral secretion. Usually
presented with pain, erythema and oedema of tissues surrounding the nail,
later on if no treated abscess may be formed.
Treatment: if the paronychia diagnosed at an early stage before abscess
formed, oral antibiotics, warm soak, rest, and elevation may be sufficient
treatment.
For abscess under nail treated by removal of nail and drainage of abscess.
3. Chronic paronychia: this occurs over several weeks, it occurs when
acute paronychia not responding to treatment especially in those whose
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hands are constantly immerse in water and in diabetic patient. it is usually
chronic infection(candida albicans).
Treatment: it may resolve if the hands are kept dry and the nail fold are
regularly dressed with antifungal e.g. clotrimazole.if no response, nail
removed.
4. Flon: closed pulp space infection of distal phalanx. This cause severs
pain in the finger pulp. Pus is trapped between the fibrous septa which bind
the fingertip skin to underlying bone this lead to painful compartment space.
The bone of distal phalanx can also become infected resulting in sequestrum.
Treatment: antiboitcs, elevation, hot soaks and drainage of abscess by
incision over the greatest tenderness.
5. Bacterail flexor tenosynovitis: there is little space within tendon
sheath, untreated infection rapidly cause adhesion and even tendon necrosis,
leading to stiff useless finger.
Most likely caused by puncture wound and the common organism are
staphylococcus or streptococcus.
Kanavel signs:
 Swollen finger held in flexion.
 Pain on passive extension.
 Tenderness over the flexor sheath.
Treatment: antibiotics, heat, elevation.and drainage by 2 incisions with
irrigation catheter and washing by normal saline.
If no response then we proceed to full exposure and wound left open.
6. Deep space infection: there are 5 potential spaces between hand
structures:
 Thenar space
 Midpalmer space
 Web space
 Thumb adductor
 Hypothenar
Of these the thenar and midpalmer space are clinically the most important.
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A penetration injury such as a splinter is often the inciting event in palmer
space infection and S.auerus is the most common pathogen.
All present with swollen hand, frog hand, very tender areas, restriction of
movement with generalized symptoms like malaise, fever.
Treatment: antibiotics, elevation, hot soack.if no response, drainage of
abscess according to site of infection, with special incision and irrigation.
7. Osteomylitis (acute and chronic): bone infection and x-ray reveal
bone destruction.
8. Bites: serious infection and subsequent loss of function can result from
animals or human bites.
Human bite is potentially serious because of virulence organism comprising
human oral flora e.g.Eikenella corrodens and staph.
Animal bites cause by domestic dog and cat ,these wound tend to be less
infected than human bite, but can cause substantial crush because of
powerful jaw of dog. Most common organism pasteurella multocida and
satph.
In both cases the region should be explored, and the wound irrigated with
normal saline ,but in case of human bite should not closed the wound
primarily but secondary closure after 7-10 days, during this period daily
change of dressing with antibiotic coverage.
9. Mycobacterial infection: tuberculosis in the hand may involve the
tenosynovium, joints or bone. The most drastic is so called compound
palmer ganglion with synovial swelling both proximal and distal to
transverse ligament.
Diagnosis confirm with biopsy. Treatment is by synovectomy and prolong
anti T.B treatment.
10.Viral infection: most commonly caused by herpes simplex virus and
called herpetic whitlow and commonly seen in dental and medical personnel,
usually presented with intense pain and erythema and small vesicular rash
usually it self limited resolve in 3-4 weeks.
Treatment: supportive care.
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