Acute Hand Infections

 

Am Fam Physician. 2019 Feb 15;99(4):228-236.

  Patient information: See related handout on hand infections, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Acute hand infections are often caused by puncture wounds and are generally classified into superficial or deep infections. Superficial infections occur in the skin and subcutaneous tissues, whereas deep infections can involve the tendon sheaths, adjacent anatomic compartments, deep fascial planes, bursae, joint spaces, and bones. Superficial hand infections are more common than deep infections and are typically managed with elevation, warm soaks, splinting in the position of function, analgesics, and empiric antibiotics when indicated. Paronychia, which can be acute or chronic, is an infection or inflammation of the nail fold. Treatment involves warm soaks, topical antibiotics, and abscess drainage, if indicated. A felon is an infection of the distal pulp of the finger. Treatment often involves surgical drainage and empiric oral antibiotics. Herpetic whitlow is caused by herpes simplex virus and typically resolves without intervention. Deep hand infections include pyogenic flexor tenosynovitis and clenched-fist bite wounds. Pyogenic flexor tenosynovitis is a rapidly progressing bacterial infection of the flexor tendon sheaths in the hand, most commonly caused by a penetrating injury to the finger. Clenched-fist bite wounds result from direct contact of the fist on incisor teeth and are associated with polymicrobial infections. Empiric antibiotics and prompt surgical consultation are indicated to reduce long-term morbidity.

The hand can easily be injured during everyday activities. Any trauma to the hand, particularly a penetrating trauma, may introduce damaging pathogens. The hand's compartmentalized anatomy may contribute to the development of an infection, and if an infection is not appropriately diagnosed and treated, significant morbidity can result.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cultures for uncomplicated superficial hand infections rarely change treatment and are not recommended.

C

26

Clenched-fist bite wounds should be allowed to heal by secondary intent, and prophylactic antibiotics should be prescribed.

B

1923, 55


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cultures for uncomplicated superficial hand infections rarely change treatment and are not recommended.

C

26

Clenched-fist bite wounds should be allowed to heal by secondary intent, and prophylactic antibiotics should be prescribed.

B

1923, 55


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN INFECTIOUS DISEASES

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.

American College of Emergency Physicians


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN INFECTIOUS DISEASES

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.

American College of Emergency Physicians


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm.

Some general wound care principles apply to all hand infections.1 Initial nonsurgical management of superficial infections includes rest, elevation, and splint immobilization in the position of function (Figure 1).1 Splints are indicated for rest and prevention of flexion contractures, elevation reduces edema, and warm compresses improve blood flow and antibiotic delivery.2,3 Open wounds should be copiously irrigated with tap water or saline, and abscesses should be drained.46 Surgical debridement may be necessary to remove n

The Authors

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CAITLYN M. RERUCHA, MD, is a student at the U.S. Army Command and General Staff Officer College, Fort Leavenworth, Kan. At the time the manuscript was written, she was a faculty member in the Department of Family and Community Medicine at Carl R. Darnall Army Medical Center, Fort Hood, Tex. She is also an assistant professor at the Uniformed Services University of the Health Sciences, Bethesda, Md., and an adjunct assistant professor at Texas A&M University College of Medicine, Temple....

JOHN T. EWING, DO, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences and faculty at the Naval Medical Center Camp Lejeune (N.C.) Family Medicine Residency.

KATHRYN E. OPPENLANDER, MD, is chief resident at Carl R. Darnall Army Medical Center Family Medicine Residency.

WESLEY CHARLES COWAN, MD, is the medical officer for the U.S. Marine Corps School of Infantry–East, Camp Geiger, N.C.

Address correspondence to Caitlyn M. Rerucha, MD, Lewis and Clark Building, 100 Stimson Ave., Fort Leavenworth, KS 66027 (e-mail: cmreruchamd@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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