Infections of Deep Hand and Wrist Compartments

Abstract

The human hand is the most exposed part of the body to highest risk for injuries, loss of the skin integrity, and to the inoculation of bacteria, most commonly Staphylococcus aureus, Streptococcus β-haemolytic, and gram-negative. In case of an infection, the mobile anatomical structures and the synovial membranes in close proximity to each other may spread the pus towards deep spaces and compartments. Mild early infections without an abscess formation may respond to antibiotics, but at more advanced stage, erythema, swelling, stiffness, and severe pain may ensue. Abscess formation will cause debilitating pain, fever, systemic symptoms, and even sepsis. Necrotizing infections may threaten not only the limb, but also patient's life. Therefore, an initially "trivial" hand injury should never be neglected, as it might turn into a deep space infection, which must be treated immediately with drainage, wound debridement, and i.v. antibiotics. Delay in diagnosis and inadequate initial management might rapidly lead to abscess formation, destruction of the gliding surfaces and the normal anatomy, and irreparable functional deterioration.

Keywords: Parona’s space; hand and wrist compartments; hand infection; necrotizing fasciitis; pyogenic flexor tenosynovitis; septic arthritis.

Figure 1

66-year-old male, seven days after a wood-thorn puncture in the index fingertip (A,B). Severe infection expanded to tenosynovitis, osteomyelitis of the distal phalanx (C), and septic arthritis of DIP joint. After debridement (D,E) viable tissue was left only in the proximal half of the index, which has been amputated (F–H) distal to the PIP joint.

Figure 2

Deep infection at the thenar and the mid-palmar spaces, one week after a penetrating injury at the palmar aspect of the 1st phalanx of the thumb. The markings (A,B) demonstrate the margins of cellulitis at presentation, which improved significantly after administration of iv clindamycin and aminoglycoside for 24 h. Through a palmar incision, the palmar inter-muscular space of the thenar and the mid-palmar space were drained and debrided (C), followed by the dorsal thenar compartment debridement (D). The elastic tubes serve for the drainage until the wounds become dry.

Figure 3

A neglected puncture wound at the ulnar side of the palm led to abscess formation into the hypo-thenar (A). Treatment included drainage, irrigation (B), and careful debridement protecting the ulnar neuromuscular bundle (C).

Figure 4

“Horse-shoe” abscess extended through the carpal tunnel, to the Parona’s space and the distal forearm.

Figure 5

Necrotic cellulitis of the thumb (A,B), rapidly developed lymphangitis and spread till the lymph nodes of the distal humerus (C).

Figure 6

71-year-old farmer with a fusiform middle finger after penetrating injury 17 days ago through the dorsal skin just proximal to the DIP joint (A,B). He received analgesics and ampicillin per os in the last six days. The patient developed osteomyelitis of the middle phalanx and septic arthritis of the DIP joint (C). After debridement he underwent amputation at the PIP joint level.

Figure 7

Thenar space infection due to penetrating wound in the palmar surface (A). Infection is extended to distal forearm (B). Thenar space, carpal tunnel and Parona’s space were incised, drained and thoroughly irrigated while median nerve is recognized and protected (C,D). Continuous postoperative irrigation can be applied without preventing early postoperative mobilization (E).

Figure 8

Infection at the distal phalanx of the thumb after a crash injury left for secondary healing (A), Thorough debridement from a lateral approach (B), antibiotic-loaded bone cement spacer for three weeks and wound closure (C,D). The spacer will be replaced with bone graft at a second stage.