(+)ScottC.Sherman,MD
AssociateProfessorofEmergencyMedicine,Rush
MedicalCollege;AssistantProgramDirector,Cook
CountyEmergencyMedicineResidency;Physician
AssistantResidencyDirector,Chicago,Illinois
AdvancedPracticeProvider
Academy
April14‐18
SanDiego,CA
EvaluationoftheHand:HowtoExaminetheHand
andEvaluatethePatientwithHandProblems
Theabilitytoproperlyexaminethehandisanessential
skillforanyproviderworkingintheED.Patients
frequentlypresentwithhandpain,handinfectionsor
handinjuries.Thespeakerwillreviewthefunctional
anatomyofthehandandwillexplainhowtoperforma
goaldirectedhandexamination.Commonhanddisorders
willalsobediscussed.
Objectives:
 Reviewthefunctionalanatomyofthehand.
 Describehowtoperformagoaldirected,time
efficienthandexamination.
 Listcriticalhigh‐riskhandproblemsthatyoucan’t
affordtomissincludingforeignbodies,highpressure
injectioninjuries,tendonlacerationsanddeepspace
infections.
Date:4/14/2014
Time:3:30PM‐4:00PM
CourseNumber:MO‐13
(+)Nosignificantfinancialrelationshipstodisclose
High-Risk Injuries and Infections
of the Hand
Scott C Sherman, MD
Associate Professor of Emergency Medicine
Rush Medical School
Department of Emergency Medicine
Cook County Hospital (Stroger)
ssherman@ccbh.org
Hand injuries account for up to 15% of all trauma cases seen in the emergency
department1. These injuries are important because the disability that can result disrupts a
patient’s daily life and livelihood. These injuries represent a significant source of
malpractice claims.
Hand Anatomy
A. Surface anatomy: Use the terms volar (palmar), dorsal, radial, and ulnar. The
creases on the volar aspect are named the proximal and distal palmar crease. The
distal palmar crease overlies the mid point of the proximal finger phalanx.
B. Skin: The skin of the volar hand and fingers is fixed to the underlying bone by
fibrous septa. This helps with grip, limits movement, and does not allow
significant swelling. The dorsal hand has looser, thinner skin. This allows a fairly
extensive space for swelling from trauma or infection.
C. Nail: The nail complex consists of the eponychium (cuticle), perionychium (nail
edge), hyponychium (under the tip of the nail), and the nail bed or matrix (under
the nail plate).
Hand Examination
A. Neurologic assessment:
1. Digital nerve: Use two-point discrimination with a paper clip. Normal twopoint discrimination is between 2 and 5 mm at the volar fingertip. Test an
uninjured finger to estimate the patient’s normal ability. Start at 1 cm, and
decrease the distance until two points are no longer felt. Test one digital nerve
at a time by placing both points of the paper clip on the same side of the
fingertip.
1
2. Forearm injuries may result in neurologic deficits in the hand. It is important
to document these at the time of the initial exam.
Radial nerve: Sensory function is assessed at the dorsal web space of the
thumb and index finger. Motor function is tested by assessing extension of
the wrist or fingers.
Ulnar nerve: The sensory function is tested at the volar tip of the small
finger. The ulnar nerve innervates the intrinsic muscles of the hand. Have
the patient spread the digits against resistance. Another reliable test for the
function of this nerve is to have the patient place the ulnar edge of the
hand on the exam table, and then have them attempt to abduct the index
finger against resistance.
Median nerve: Sensory function is assessed at the volar tip of index
finger. Motor strength is best assessed by thumb abduction (have the
patient raise the thumb towards the ceiling while the dorsal hand is flat on
the exam table). This tests the function of the abductor pollicis, which is
reliably innervated by the motor nerve branch of the median nerve.
B. Tendon assessment:
1. With injuries that lacerate or penetrate, it is important to document tendon
function. Excess flexion occurs with an extensor tear, while excess extension
is seen with flexor tendon injuries.
2. Each finger should be examined independently for flexion of the distal
phalanx (profundus tendon) and the whole finger (superficialis tendon).
Testing is performed against resistance. Any weakness or pain might indicate
a partial injury.
3. Open injuries need to be assessed with a bloodless field and direct inspection
of the tendon through a full range of motion. Tendon lacerations are missed in
approximately 1/3 of instances2.
C. Vascular assessment:
1. Injuries to vascular structures usually do not affect perfusion of the hand
because of extensive anastomoses.
2. If initial inspection reveals a dusky or cool finger or hand, prompt intervention
is needed. Capillary refill and pulse oximetry waveforms can give some
indication of blood flow to injured digits.
D. Anesthesia
1. Sensory examination must always precede anesthesia.
2. Wrist block includes:
Radial nerve: Lateral to radial artery and skin wheal on dorsum of hand
Median nerve: Between the flexor carpi radialis and palmaris longus
tendons at wrist crease
Ulnar nerve: Lateral to the flexor carpi ulnaris tendon
3. Digit block options include:
Half ring block: Each side of the base of the digits
Metacarpal block: Between the metacarpal heads all the way to the
palmar aspect of the hand
2
Transthecal block: In the center of the proximal digital crease. Go to
bone, pull back slightly, and then inject. Direct injection into the flexor
tendon sheath.
4. Epinephrine injection into the digits has been considered taboo since the
1950’s. A 2005 study of over 3,000 hand surgeries using the typical
concentrations included with local anesthetics (1:100,000) did not find a
single case of digital ischemia3. Epinephrine, in the proper concentration, is
safe to use in the digit, and is advantageous because it increases duration of
anesthesia and decreases bleeding4-9.
Splints and Dressings
A. Hand position: The best position to splint the hand is the position of function
with the wrist extended 15-30º, the MCP joints flexed 60-90º, and the IP joints
flexed 10-15º. Flexion of the MCP joints is important because the collateral
ligaments are stretched the most in this position (avoiding contracture) and the
joint is most stable. This position is sometimes referred to as the “safe” position.
When the MCP’s are at 90º, the term “intrinsic plus” is used.
B. Universal hand dressing: This dressing is used in inflammatory conditions of the
hand. Unfolded 4x4 gauze is placed between the digits and the hand is wrapped
with an elastic bandage. Holes are cut for the fingers and the wrist is taped in
slight extension. This position allows for the best lymphatic drainage so that
swelling subsides more rapidly.
C. Gutter splint: This splint is useful for phalanx and metacarpal fractures. Ulnar
gutter splint immobilizes the 4th and 5th digits, while the radial gutter is used for
injuries to the 2nd and 3rd digits. The hand is immobilized in the “safe” position.
For the radial gutter, cut out a hole for the thumb. In both splints, remember to
place cotton padding between the digits.
D. Dynamic finger splint: This splint immobilizes the injured digit to the adjacent
uninjured digit and allows for motion at the MCP and PIP joint. This splint is
useful for ligamentous injuries of the digits. Cotton padding should be placed
between the digits.
Hand Fractures
A. Rotational deformities. It is important to detect and correct any rotational
deformities before healing occurs, as later repair is difficult. 5 degrees of
metacarpal shaft rotation can result in 1.5 cm of digital overlap10. Rotational
deformities are detected by having the patient flex the fingers, noting that the nail
plates are parallel and that all the fingers “point” to the same location on the base
of the hand.
3
B. Metacarpals 2 – 5 (index through little finger):
1. Head fractures: Usually due to direct blow, and often comminuted or
crushed. Treatment with hard or bulky splints, and ortho follow-up.
2. Neck fractures: Classic is “boxers” fracture (5th metacarpal neck), which
accounts for 5% of all upper extremity fractures, 10% of hand and wrist
fractures, and 20% of hand fractures11-13. Usually angulated in a volar
direction. Treatment varies for index and middle finger metacarpals,
where anatomic alignment is much more important. Ring and little finger
metacarpals can tolerate more angulation without functional impairment.
Management of boxer’s fractures remains controversial. Recommendation
regarding the degree of angulation acceptable before closed reduction is
deemed necessary varies from 20-70º. Problems with closed reduction
include difficulty in maintaining reduction and little influence of
angulation on functional outcome. If closed reduction is to be attempted,
the most common method involves placing the MCP and PIP joints in 90
degrees of flexion and pushing the digit dorsally, allowing the base of the
proximal phalanx to push the metacarpal head back into proper alignment
(90-90 method). Further treatment recommendations vary widely from an
elastic bandage to functional splinting to plaster splinting14-25.
3. Shaft fractures: Often angulated, sometimes spiral or oblique. The more
proximal the fracture, the more important anatomic reduction becomes.
These should be splinted and referred in a timely fashion.
4. Base fractures: Uncommon, and often interarticular. Can affect the
carpometacarpal function. The base of the little finger MC may present
with a fracture-dislocation, as the fragment is pulled by the attachment of
the extensor carpi ulnaris. Splint and refer.
C. Thumb metacarpal:
1. Base fractures. These are often comminuted and dislocated, as the
abductor pollicis longus tendon pulls the fragments. A single fracture with
this finding is called a “Bennett’s” fracture, while a comminuted fracture
(often “T” or “Y” shaped) is called a “Rolando’s” fracture. These
fractures require fixation (percutaneous wires or ORIF) if they are > 1 mm
displaced26.
4
Rolando’s Fracture
Bennett’s Fracture
D. Phalanx fractures:
1. Tuft fracture: Crush injuries. These are open fractures, if the skin is
disrupted. Antibiotics can be administered, although infection is
uncommon. Treated with a protective dorsal splint.
2. Shaft fracture: Often spiral or oblique, these will frequently require
fixation. Initial reduction will often not be maintained, even with splints or
buddy taping. Rotation is again important to detect.
3. Intra-articular fracture: These may need reduction if significant portions
of the joint are involved. “Mallet” finger fracture occurs with a flexion
force applied to the tip of the extending finger. The force causes an
avulsion of the extensor tendon at the dorsal base of the distal phalanx.
The treatment is splinting in extension for 6 weeks27. If greater than onethird of the joint space is involved, surgical repair may be indicated28.
Bony Mallet Finger
5
Finger Dislocations
A. Interphalangeal joint dislocation
1. The IP joints of the fingers have collateral ligaments and a fibrous volar
plate. Dorsal support is minimal and includes the extensor mechanism and
dorsal capsule. Dislocation commonly injures the ligamentous structures
of the joint.
2. The PIP is much more commonly dislocated—usually dorsal. Volar
dislocations result in injury to the central slip of the extensor tendon and
may result in a boutonniere deformity (see below)29.
3. After a digital nerve block, reduction is achieved with gentle traction.
Irreducible dislocations are unusual, but indicate entrapped soft tissues or
bony fragments that usually must be removed in the operating room30-33.
4. Obtain a radiograph, as tiny fragments of avulsed bone at the joint signify
ligament avulsion.
5. Re-examine the joint post-reduction to check for laxity suggestive of
significant ligamentous injury. If there is maintenance of reduction
through the full ROM, then adequate ligamentous support is assumed.
Wide opening on lateral stress testing suggests injury to both the collateral
ligament and volar plate.
6. Splint the joint in 20-30 degrees of flexion. If the joint is stable postreduction, some advocate early motion with dynamic splinting. Open
injuries need orthopedic consultation for debridement, irrigation,
antibiotics, and close follow-up.
Dorsal PIP Joint Dislocation
B. Metacarpophalangeal joints:
1. The MCP joints have unique anatomy that provides strength and range of
motion. The transverse metacarpal ligament provides support by attaching
the MCP joints to each other (except the thumb). There are also collateral
ligaments, which are supported by the lumbrical muscles. The
arrangement provides the ability to abduct when extended, but not when
flexed.
2. The complex anatomy protects against dislocation, but also leads to a
higher incidence of irreducible dislocations. The most common
dislocations are dorsal, and fall into two broad categories34.
6
3. “Simple” dorsal dislocations have a dramatic appearance clinically, with
the MCP joint held in 60-90 degrees of hyperextension. This dislocation is
usually easily reduced with closed techniques. Reduction is achieved by
further hyperextension of the MCP joint, followed by dorsal pressure at
the base of the proximal phalanx. Longitudinal traction may convert a
simple dislocation into a complex one35. After successful reduction,
immobilize the MCP joint in 60 degrees of flexion36,37.
4. “Complex” dorsal dislocations appear subtle clinically, with the proximal
phalanx nearly parallel to the metacarpal. Other findings include a
palpable metacarpal head on the volar surface with dimpling of the palmar
skin. They are often impossible to reduce with closed techniques due to
the interposition of torn ligaments and the arrangement of ligaments and
lumbrical muscles that actually tighten around the head of the metacarpal
as traction is applied, which prevents reduction.
C. Gamekeeper’s thumb: This injury is a sprain or tear of the ulnar collateral
ligament of the thumb MCP joint from forced radial deviation of the thumb (e.g.
falling with a ski pole in the hand). The end result is pain and potential laxity
with gripping. Recovery is slow and surgery may be needed. Initial treatment is
with a thumb spica splint.
Tendon Injuries
A. Extensor tendons:
1. More superficial with thinner skin. Easily lacerated. Tendon injury may be
“open” or “closed”.
2. Open extensor tendon injuries are divided into 8 zones. Zone I is over
the distal IP joint. Zone II includes the middle phalanx. The zones of
extensor tendon injury can be more easily remembered by noting that odd
number zones are over joints, while even numbered zones are over
bones38. Zone VII and VIII involve the carpal bones and distal forearm,
respectively. An emergency physician can repair complete tendon injuries
in zones IV, V, and VI. Other complete extensor tendon ruptures should
be referred to a hand surgeon after suturing the skin and splinting the
hand. Partial open tendon ruptures should be referred, but do not require
repair in most instances39,40.
3. Closed extensor tendon injuries include mallet finger, rupture of the
central slip, and boxer’s knuckle.
a. Mallet finger: Tearing of the insertion of the extensor tendon from the
base of the distal phalanx is known as a “mallet finger”, and is treated
with the joint in extension for 6 weeks. The patient is cautioned not to
remove the splint during this time.
b. Central slip rupture: The central slip of the extensor tendon is
located at the base of the dorsal middle phalanx. At this location, the
tendon splits into three parts, with the central slip attaching to the
bone, and the two lateral parts attaching to the distal phalanx with the
7
lumbrical muscles. When the central slip is ruptured secondary to
contusion, forced flexion, or dislocation of the PIP joint, the extensor
tendon splits and can slip to either side of the joint. In that position,
attempts at extension actually cause some flexion. The end result is a
“Boutonnière deformity”, where the proximal joint is flexed while the
distal joint is hyperextended. The deformity may not be clinically
apparent for 2-3 weeks, but central slip rupture should be expected
when there is extension lag, pain with extension, or pain with resisted
extension. If the injury is suspected, immobilize the PIP joint in full
extension with a dorsal or volar splint with DIP joint unrestricted38.
c. Boxer’s knuckle: Rupture of the extensor hood occurs as a result of
injury to the dorsal aspect of the hand over the MCP joint. In this
scenario, there is disruption of one of the laterally located sagittal
bands that hold the tendon in a central location. The end result is
subluxation of the tendon. These injuries should be splinted and
referred. Splint the hand in only as much extension as is required to
keep the tendon in its proper position41-43.
B. Flexor tendons:
1. Open flexor tendon injuries. There are anatomical “zones” for flexor
tendon injuries, with associated unique problems for healing and repair.
Flexor tendon injuries require repair by a hand surgeon.
a. Zone 1: From the mid portion of the finger to the insertion of the
profundus tendon. Problems with retraction of the proximal part and
the complex pulley system. The FDP emerges from the split FDS in
this zone.
b. Zone 2: From the distal palmar crease to zone 1, where the FDS and
FDP interweave. This area is known as “no man’s land” because the
complex relationships of multiple tendons, sheaths, and pulleys, make
repair difficult. Any scarring leads to long-term functional deficits.
This is the most common area for injury.
c. Zone 3: Mid palm from level of thenar eminence to proximal edge of
flexor sheath. Easier repair with less pulleys and better visualization.
d. Zone 4: Carpal tunnel area, multiple tendons usually involved.
e. Zone 5: Proximal to the carpal tunnel.
2. Closed flexor tendon injury. Jersey finger. This injury is an avulsion of
the flexor digitorum profundus where it inserts on the distal phalanx. The
injury gets its name from the common mechanism of forceful extension
(during active flexion) of the DIP joint, when a football player grabs an
opponent’s jersey with the tip of the finger while that player pulls away44.
8
The index finger is involved in 75% of cases. On examination, there will
be loss of flexion at the DIP joint with normal ROM at the PIP and MCP
joints. Splint the finger with a dorsal splint with the wrist flexed 30
degrees, MCP joint flexed 70 degrees, and the IP joints flexed 30
degrees45. Primary repair is recommended and is best accomplished when
the injury is diagnosed acutely46.
Fingertip Injuries
A. Anatomy: The fingertip is defined as the structures distal to the insertion of the
flexor and extensor tendons on the distal phalanx. It is comprised of the nail,
nailbed, pulp, and distal phalanx. The nailbed is comprised of a germinal and
sterile matrix. The germinal matrix is proximal, ending at the lunula, and accounts
for approximately 90% of nail growth. The sterile matrix makes up the majority
of the nailbed and helps keep the nail tightly affixed to the finger. The proximal
nail fold is termed the eponychium, while the distal junction of the nailbed and
fingertip skin is the hyponychium. The dorsal roof of the proximal nail fold is
responsible for the nail’s shine.
B. Subungual hematoma: In patients with an uncomplicated subungual hematoma
involving >50% of the nail plate, the incidence of a nailbed laceration is 60%47.
However, nail trephination alone (for symptomatic relief), results in a good
cosmetic result without complications no matter how large the hematoma or
whether a fracture is present48-50.
C. Nailbed injury: If the nail is avulsed or lacerated, it is recommended to remove
the nail and repair injuries to the nailbed. The finger is blocked and a tourniquet is
applied. The nailbed is approximated with 6-0 or 7-0 absorbable sutures51.
Following repair, the nail is replaced in the proximal fold and sutured in place for
7-10 days. This practice is felt to help protect the nailbed and eponychium to
allow for growth of the new nail, although it has not been well studied52,53. If the
nail is unavailable, petroleum gauze is used as an alternative.
D. Fingertip amputation: This is a common injury in both adult laborers and
children who accidentally close their finger in a door54. Treatment is
controversial55. Options include skin grafts, replantation, flaps, and conservative
management (secondary intention)56. Prophylactic antibiotics are indicated only in
grossly contaminated wounds57. Conservative treatment with a non-occlusive
(Vaseline gauze) appears to be equally efficacious or better than many surgical
options as confirmed by multiple studies58-68. The authors of these studies cite the
natural regenerative properties of the fingertip, simplicity, decreased cost,
preservation of length, improved cosmesis, low incidence of painful neuromas
and stiffness, and good return of sensation. This technique is employed in children
and adults, and while more common when no bone is exposed, it also has been
successful when the distal phalanx is exposed (even without trimming back the
bone)58,63. Disadvantages include higher incidence of nail deformity and the need
for frequent dressing changes. Replantation is an expensive option requiring a
surgeon skilled in microvascular techniques, but when successful, sensation,
9
length, cosmesis, and ROM are preserved and the incidence of chronic pain is
low69-71. Success rates range from 70-90% and children do especially well. If the
amputation is proximal to the lunula, this is the only procedure that will preserve
the nail. Because the amputated tip does not possess muscle, the period of
ischemia which allows successful replantation is prolonged (8 hours warm; 30 hrs
cold)57.
Amputation
A. All amputated parts should be considered for replantation. The classic indications
include: amputation between PIPJ and DIPJ; thumb; multiple digits; child;
midpalmar amputation; and wrist or forearm. Success is not only related to
viability, but also the restoration of a functional hand.
B. Care of the stump includes achieving hemostasis first. Point control of a bleeding
vessel with a pressure dressing is usually the initial method. Proximal tourniquets
are discouraged unless being used for temporary control or in a patient with lifethreatening bleeding. Use for greater than 3 hours may lead to irreversible
ischemia. Blind ligation or clamping may lead to unnecessary damage to the
nerves or vessels72.
C. Care of the amputated part involves gentle cleansing if heavily contaminated,
wrapping in moist gauze, and storage in a sealed plastic bag. The bag is then
placed into another bag filled with ice water. Properly maintained digits have
about 12 hours of viability.
D. Prophylactic antibiotics and tetanus are indicated.
E. It should always be emphasized the replanted digit will never function normally,
and will likely have some sensory problems, as well as chronic stiffness and
weakness.
10
Bite Wounds
A. Human bites:
1. 35 different bacteria were isolated from the wounds of patients with
human bites, Eikenella corrodens was present in only 17%73. Overall
infection rate is 10%. Amoxicillin clavulanate (Augmentin) is the drug of
choice for human bites and should be administered routinely for wounds
to the hand74. HIV and other blood borne viruses have been transmitted
through human bites and post-exposure prophylaxis should be
considered75-77.
2. In one study, 38% of patients with human bites did not reveal the
mechanism of injury until after they were specifically questioned78.
Always take a thorough history and emphasize the importance of knowing
the true mechanism—higher infection rate.
3. Fight bite injuries (i.e. clenched fist injuries) occur over the dorsum of
the hand at the MCP joint, frequently involving the extensor tendon and
joint space. The injury is sustained following a punch to the mouth (i.e.
tooth). A radiograph should be obtained noting any fracture, evidence of
osteomyelitis, or tooth fragments79. Treatment of an infected fight bite
injury involves hand consultation for surgical debridement, irrigation, and
admission for IV antibiotics. Noninfected bites are managed after adequate
exploration defines the full extent of the injury. Because the wound is
frequently very small (3-5 mm), it should be extended so that all the
potentially injured structures are visualized80. If there is injury to the joint
capsule, tendons, or deep spaces, consultation with a hand surgeon is
obtained for possible admission. If these structures are not involved, the
wound is copiously irrigated, left open to heal via secondary intention, and
oral antibiotics are administered81. Follow-up should be arranged within
24-48 hours.
B. Dog and cat bites:
2. Animal bites account for 1% of all ED visits in the US and the hand and
upper extremity is involved in over half of adult cases73,82,83. Hand bites
have a higher rate of infection than other areas because of avascular
tendons and tendon sheaths that provide a propensity for the spread of
infection.
3. Dog: Potential for significant tissue destruction from large crushing
mechanisms (up to 450 psi). Dog bites account for 80-90% of domestic
animal bites. Obtain radiographs if any concern of bony injury. Superficial
wounds may do well with local care, but deeper wounds need debridement
and antibiotics. Infection rate is between 2-20%.
4. Cat: Deeper penetration than dog bites with the inability to cleanse or
irrigate the depth of the wound. The end result is a higher rate of
infection—30-50%83.
5. Pasteurella multocida is commonly found in both dog and cat bites (75%),
but many species of aerobic and anaerobic bacteria (up to 40 in one study)
11
have been implicated84,85. Augmentin 3-7 days as prophylaxis is the
antibiotic of choice. Doxycycline for penicillin allergic patients.
Hand Infections
A. Paronychia: This is an infection of the lateral soft-tissue fold surrounding the
fingernail. Infection may spread to the eponychium and to the opposite side and
even under the nail in advanced cases. The portal of bacterial entry is frequently
due to trauma (eg, nail biting, manicures, or a hangnail) and is more common with
excessive exposure to moisture (eg, dishwashers)86,87. Use a #11 scalpel along the
nail plate to lift (incise) the lateral nail margin until pus is expressed. If there is no
abscess, dicloxacillin and soaks may be sufficient. Untreated, a paronychia may
spread to become a felon.
B. Felon: This is an infection of the distal pulp space due to minor penetrating
trauma. Because the skin is tightly adherent to the bone, there is little room for
swelling in this area and a great deal of pain is produced. A felon is drained with
an incision over the most prominent portion of the abscess (just like any other
abscess), usually the volar aspect of the finger pad (ie, volar longitudinal
incision). Some authors feel that volar longitudinal incisions will result in painful
scars, but in fact, this incision actually avoids the nerves and circulation, and is
least likely to result in pain and fibrosis88. Alternatively, a unilateral longitudinal
incision may be employed, but the incision must be close to (approx. 5 mm) and
parallel to the nail to avoid the digital nerve86,89. For the unilateral longitudinal
incision, the non-oppositional surface of the involved digit should be used (eg,
ulnar side of index finger). Avoid lengthy and deep incisions, which can cause the
fingertip to become unstable. The fibrous septa that tether the skin to the bone do
not compartmentalize the fingertip, as is commonly believed88. Therefore deep
incisions to cut the septa will only produce an unstable finger pad and not
improve outcome86. Instead of a deep incision, careful blunt dissection is carried
out until the abscess is adequately decompressed. Packing is placed loosely for a
period of 24-48 hours, antibiotics are prescribed, and close follow-up is
arranged90.
C. Flexor Tenosynovitis is a serious infection that can follow minor finger injuries
in which the tendon sheath is penetrated. The tendon sheaths allow spread of the
infection from the DIPJ to the mid palmar crease. In the case of the thumb and
little finger, the sheaths extend to the wrist and communicate in 50-80% of the
population. An infection of this communication is called a “horseshoe abscess”89.
The classic presentation is the “four signs of Kanavel”: Tenderness along the
tendon sheath; Digit held in slight flexion; Pain with forced extension; Diffuse
“sausage like” swelling of the digit. Pain with passive extension is the most
clinically reproducible sign and is best elicited by extending the finger using the
tip of the patient’s fingernail. Early diagnosis and treatment are necessary to
reduce the incidence of adhesion formation within the sheath. Initial treatment
includes splinting, IV antibiotics, and prompt surgical referral. Surgical drainage
is indicated if improvement is not seen in the first 24 hours, and involves
12
proximal and distal tendon exposure with the insertion of a catheter for copious
irrigation90,91.
D. Deep Space Infections represent 5-15% of hand infections92. Without knowledge
of these infections, they may be confused with a more superficial hand abscess or
cellulitis. There are five deep space infections and each one presents with
characteristic findings that will help lead to the diagnosis. All of these infections
require hand consultation for drainage. Web space (collar button abscess):
Significant swelling and pain in the web space and distal palm with the fingers
slightly abducted. Drainage via a longitudinal incision in the web space.
Midpalmar space: Maximal tenderness in the mid palm with loss of the normal
concavity of the palm. Dorsal subaponeurotic space: Located between the
extensor tendons and metacarpals. Dorsal hand swelling that is tender to palpation
with painful finger extension. Thenar space: Tenderness and swelling within the
thenar space with limited movement of the thumb. The thumb is held in abduction
and flexion to increase this potential space90. Hypothenar space: Rare infection
with swelling and tenderness in the hypothenar area.
Thenar Space Infection
Other Conditions
A. Tendonitis: In the hand and wrist, tendonitis occurs where tendons pass through
the flexor and extensor retinaculum. When the first compartment of the extensor
tendons (APL and EPB) is affected, De Quervain’s tenosynovitis
(washerwoman’s sprain) is present. The patient experiences pain over the radial
portion of the wrist, where there may be visible swelling93. There is a marked
increase in pain with the thumb folded into the palm and the wrist ulnar deviated
(Finkelstein test). Treatment is NSAIDs and immobilization with a thumb splint.
Injection with local anesthetic and steroid has a success rate of up to 90% and is
13
attempted when more conservative treatment has failed94. The needle is placed
into the first compartment and directed proximally towards the radial styloid95.
Intersection syndrome (oarsman’s wrist) is inflammation of the tenosynovium of
the second extensor compartment (ECRL and ECRB) where it “intersects” under
the obliquely oriented APL and EPB. Tenderness is elicited 4-6 cm proximal to
Lister’s tubercle. Treatment is similar. Trigger finger (digital flexor
tenosynovitis) occurs when a thickening of the tendon catches at the first annular
pulley. Patients complain of intermittent, painful catching. If the digit is locked,
surgical or percutaneous release is indicated. The most common location is the
thumb and ring finger, but any digit may be affected. Tenderness is elicited in the
distal palm96. Palmar injection into the tendon sheath just distal to the metacarpal
head is curative in 85% of cases97.
B. Compartment syndrome: There are 10 compartments of the hand (4 dorsal
interosseous, 3 palmar interosseous, hypothenar, thenar, and adductor
compartments). The digit also has isolated compartments separate from the
palm98. The most common etiology is an infiltrated IV or arterial line. Other
causes include fractures, high pressure injection injuries, crush injuries, or tight
fitting casts. Pain refractory to medications, pain with passive stretch, and tense
compartments are characteristic findings. When clinical suspicion is present,
consultation with a hand surgeon is recommended for measurement of
compartment pressures and fasciotomy.
C. High pressure injection injuries: Secondary to paint guns, grease guns, or diesel
injectors99. High pressures (up to 10,000 psi) deposit material deep into the
tissues, tendon sheath, and between fascial planes. The kinetic energy produced
by this type of injury is equivalent to a 450 lb weight dropping 25 cm100. The
injury usually occurs due to attempts to clear the “blocked” tool with the nondominant hand. The index finger is most commonly involved, followed by the
middle finger and then palm. The flexor tendon sheath is more commonly
penetrated with injuries at the DIP and PIP flexor creases. Injuries of the thumb
and little finger are problematic because the tendon sheaths are contiguous with
the radial and ulnar bursae, permitting spread to the forearm. Paint and paint
thinner produce a larger inflammatory response than grease, and therefore a
higher rate of amputation. The initial injury often looks benign, so delayed
presentations are most common101. Within hours, the finger starts to become
painful due to vasoconstriction and the inflammatory response. The risk of
amputation is greater when the patient presents > 10 hours after injury. Digital
blocks are contraindicated because they further increase the tissue pressure.
Treatment includes prophylactic antibiotics, tetanus, and surgical decompression
with removal of the foreign material in the operating room102.
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