Hand Case Discussion 1.2

Hand Icon

Presented by: Jeff McMenomy, MD

CC: “My finger hurts.”

HPI: A 56 year-old right hand dominant male with history of type II diabetes mellitus presents with complaint of progressively worsening right index finger pain and swelling.  He says symptoms began about 6 hours ago.  He denies any trauma to the finger.  He complains of pain with any movement of the finger and states that he has exquisite pain whenever the finger accidently bumps against an object.  He has never had finger pain like this before.  This patient denies any fever or chills.

Past Medical History: Diabetes mellitus type II, hypertension

Past Surgical History: Tonsillectomy and adenoidectomy as a child

Family History: Positive for diabetes and hypertension; negative for heart disease or stroke

Social History: 10 pack-year smoking history, quit 5 years ago; denies ethanol or illicit drug use

Allergies: No known drug allergies

Medications: metformin, hydrochlorothiazide

Physical Exam:

Temp 36.8,     HR 92,     BP 140/91,     RR 18,      O2 Sat 98% on room airConstitutional: Alert and Oriented x 3, nontoxic-appearing

Musculoskeletal:

Right index finger is uniformly swollen and held in partial flexion.  This finger is exquisitely tender along the flexor surface and tenderness extends proximal to the flexor surface of the hand over the second metacarpal. The right index finger is only mildly tender over the extensor surface and there is no tenderness elsewhere on the hand or over any of the other fingers.  Patient has exquisite tenderness with passive extension of the right index finger but only mild tenderness with passive flexion.  There is mild erythema over the flexor surface of the right index finger which does not extent to the rest of the hand or to any other fingers.  There is no palpable fluctuance.  Patient is able to actively flex and extend at all joints of the right index finger, including the distal interpahalangial joint when this joint is isolated.  He does, however have pain with these movements.  There is no pain or deficits with active flexion or extension of any of the other fingers of the right hand.

Radiographs: Three-view x-ray of right index finger and hand shows soft tissue swelling of right index finger but no fracture or dislocation

Questions:

1.  Given this patient’s presentation, which of the following possible condition is of greatest concern?

a.  Dorsal finger soft tissue abscess with surrounding cellulitis

b.  Felon

c.  Flexor tendon tenosynovitis

d.  Herpetic whitlow

e.  Traumatic rupture of flexor tendon

2. What is the definitive treatment for the condition of greatest concern in this patient?

a.  Bedside nail bed repair, splinting, and arrange for follow-up in hand surgery clinic

b.  Bedside repair of ruptured tendon and arrange for follow-up in hand surgery clinic

c.  Hand surgery consult for operative intervention with initiation of parenteral antibiotics

e.  Local incision and drainage of abscess with gauze packing strip and follow-up in 2 days for wound check and removal of packing gauze

f.  Prescription for oral acyclovir, hand hygiene recommendations, and primary care follow up

3. What is the most common organism isolated from such lesions?

a.  Herpes simplex virus type 1

b.  Herpes simplex virus type 2

c.  Neisseria bacteria

d.  Pseudomonas bacteria

e.  Staphylococcus bacteria

Answers:

1.  c.  Flexor tendon tenosynovitis

The most concerning condition consistent with this patient’s signs and symptoms is flexor tendon tenosynovitis.  The classic description of flexor tendon tenosynovitis involves Kanavel’s four cardinal signs, all of which are present here.  There are: tenderness over the flexor tendon sheath, uniform swelling of the involved digit, pain with passive extension, and a semiflexed resting position of the involved digit.  Such infections are most commonly caused by penetrating trauma but commonly patients do not recall any trauma to the digit.

2.  c.  Hand surgery consult for operative intervention with initiation of parenteral antibiotics

Early recognition of this condition and evaluation by a hand surgeon for prompt operative intervention is essential.  Delay in recognition and treatment may result in loss of use of the involved finger and possibly the involved hand.  All patients must be admitted to the hospital and IV antibiotics should be started promptly.

3.  e.  Staphylococcus bacteria

Staphylococcus is the most common bacteria isolated in such infections and antibiotic coverage should cover this organism.  If MRSA is suspected, vancomycin may be administered.  Neisseria gonnorrhoeae should be considered in all patients with suspicion for sexually transmitted infection and is a possible hematogenous source, especially in patients with no history of penetrating trauma to explain the source of infection.  Ceftriaxone may be considered in such patients.

References

JA Marx, et al. (2006). Rosen’s Emergency Medicine: Concepts and Clinical Practice, Sixth Edition. Philadelphia: Mosby Elsevier.

JE Tintinalli, GD Kelen, JS Stappczynski. (2004). Emergency Medicine: A Comprehensive Study Guide, Sixth Edition. Chicago: McGraw-Hill.

RG Hart, DT Uehara, MJ Wagner. (2001).  Emergency and Primary Care of the Hand. Dallas: American College of Emergency Physicians.

“Hand Case Discussion” is an educational module that focuses on the diganosis and management of Hand pathology that commonly presents to the Emergency Department.

Hand Case 1.2

Hand Icon

Presented by: Jeff McMenomy, MD

CC: “My finger hurts.”

HPI: A 56 year-old right hand dominant male with history of type II diabetes mellitus presents with complaint of progressively worsening right index finger pain and swelling.  He says symptoms began about 6 hours ago.  He denies any trauma to the finger.  He complains of pain with any movement of the finger and states that he has exquisite pain whenever the finger accidently bumps against an object.  He has never had finger pain like this before.  This patient denies any fever or chills.

Past Medical History: Diabetes mellitus type II, hypertension

Past Surgical History: Tonsillectomy and adenoidectomy as a child

Family History: Positive for diabetes and hypertension; negative for heart disease or stroke

Social History: 10 pack-year smoking history, quit 5 years ago; denies ethanol or illicit drug use

Allergies: No known drug allergies

Medications: metformin, hydrochlorothiazide

Physical Exam:

Temp 36.8,     HR 92,     BP 140/91,     RR 18,      O2 Sat 98% on room airConstitutional: Alert and Oriented x 3, nontoxic-appearing

Musculoskeletal:

Right index finger is uniformly swollen and held in partial flexion.  This finger is exquisitely tender along the flexor surface and tenderness extends proximal to the flexor surface of the hand over the second metacarpal. The right index finger is only mildly tender over the extensor surface and there is no tenderness elsewhere on the hand or over any of the other fingers.  Patient has exquisite tenderness with passive extension of the right index finger but only mild tenderness with passive flexion.  There is mild erythema over the flexor surface of the right index finger which does not extent to the rest of the hand or to any other fingers.  There is no palpable fluctuance.  Patient is able to actively flex and extend at all joints of the right index finger, including the distal interpahalangial joint when this joint is isolated.  He does, however have pain with these movements.  There is no pain or deficits with active flexion or extension of any of the other fingers of the right hand.

Radiographs: Three-view x-ray of right index finger and hand shows soft tissue swelling of right index finger but no fracture or dislocation

Questions:

1.  Given this patient’s presentation, which of the following possible condition is of greatest concern?

a.  Dorsal finger soft tissue abscess with surrounding cellulitis

b.  Felon

c.  Flexor tendon tenosynovitis

d.  Herpetic whitlow

e.  Traumatic rupture of flexor tendon

2. What is the definitive treatment for the condition of greatest concern in this patient?

a.  Bedside nail bed repair, splinting, and arrange for follow-up in hand surgery clinic

b.  Bedside repair of ruptured tendon and arrange for follow-up in hand surgery clinic

c.  Hand surgery consult for operative intervention with initiation of parenteral antibiotics

e.  Local incision and drainage of abscess with gauze packing strip and follow-up in 2 days for wound check and removal of packing gauze

f.  Prescription for oral acyclovir, hand hygiene recommendations, and primary care follow up

3. What is the most common organism isolated from such lesions?

a.  Herpes simplex virus type 1

b.  Herpes simplex virus type 2

c.  Neisseria bacteria

d.  Pseudomonas bacteria

e.  Staphylococcus bacteria

“Hand Case Discussion” is an educational module that focuses on the diganosis and management of Hand pathology that commonly presents to the Emergency Department.

Hand Case 3.1

Hand Icon

Presented by: Mike Fernandes, MD

Chief Complaint: “My thumb is swollen ”

History of Present Illness:
This is a 47 year-old male presents to the emergency department’s ARC.  His primary complaint is that his right thumb is swollen.  He states that he bumped his thumb about two weeks ago on some furniture.  He  had some pain and a little swelling but nothing else.  The pain had improved after a few days, however, it started to hurt again and swell.  After a about a week and half he started to notice some purulent drainage from a little sinus at the tip of his thumb. He has some difficulty flexing his thumb at the interphalangeal joint, he is however, able to oppose his thumb.  The digit is erythematous, and swollen.  The remainder of his hand and digits are completely unaffected, the swelling and erythema is limited to the thumb.

Past Medical History: Denies, any hypertension or diabetes mellitus
Past Surgical History: Eye surgery in 2007
Medications: Eye drops
Allergies: NKDA
Social History: He denies any drug use.  He does admit to smoking 1 pack of cigarettes every 2 days, and occasionally consumes alcohol.
Family History: Significant for heart disease and diabetes

Physical Exam:

Vital Signs: BP: 142/88, P: 84, RR: 18, SpO2: 99%RA T: 36.3

Extremities: FROM, strength is 5/5 proximately and distally in both upper and lower extremities.  He is able to flex and extend at the wrist joints without any difficulty.

Hands: His MCP, PIP and DIP are completely intact with full extension and flexion from the index to the pinky finger on both hands.  He is able to oppose this thumbs bilaterally.  He is able to fully extend and flex this left thumb at the IP joint as well as abduct and adduct.  His right thumb is swollen up almost to the MCP it is  not uniformly swollen and erythematous, or warm to the touch. He is able to abduct and adduct his thumb, however, can fully flex at the IP joint because of swelling. He has pain to palpation at the distal phalanx of of the thumb; there is a whitish discoloration to the tip of the distal phalanx with a draining sinus, which did not appear to extend beyond the distal phalanx.  The nail bed appears to not be involved.  He did not have pain on passive extension of the digit, he did not have tenderness along the tendon sheath.

Radiographs
X-ray of the right hand was completely within normal limits, no bony abnormalities were noted no fracture, dislocations, or signs of osteomyelitis.  Patient did have some soft tissue swelling of the first digit, which is evident on the x-ray film.

Discussion:
A Felon is an infection of the distal pulp space of the finger.  The culprit organism usually is S. aureus or S. pyogenes, which enters the pulp space following minor trauma.  Patients present with exquisite pain, erythema, and swelling of the finger pad that overlies the distal phalanx.  This is a suppurative infection, so an abscess may develop.

By definition, a felon does not include the DIP crease.  If the edema and erythema extend that far, there may be a more serious complication; the infection may have spread to the bone and joint, invaded the tendon sheath, or formed a sinus tract to the skin.

A felon usually is caused by inoculation of bacteria into the fingertip through a penetrating trauma. The most commonly affected digits are the thumb and index finger.  Common predisposing causes include wood splinters, bits of glass, abrasions, and minor puncture wounds.  A felon also may arise when an untreated paronychia spreads into the pad of the fingertip.  Felons have been reported following multiple finger-stick blood tests.

Early infection is characterized by inflammation alone and may be treated with an oral anti-staphylococcal antibiotic such as cephalexin (Keflex) (250 to 500 mg PO QID) or dicloxacillin (250 to 500 mg PO QID).  If penicillin-allergic, erythromycin (250 to 500 mg PO QID) or clindamycin (150 to 300 mg PO QID) can be used.  If a patient is hospitalized because of comorbid or other condition, either nafcillin (1 to 2 gm IV q4-6h) or cefazolin (Ancef) (1 gm IVq6h) is recommended.  If there is suspicion for MRSA, then vancomycin should be administered.

In general, patients present for medical care after the development of an abscess.  Treatment requires incision and drainage, but incisions of the distal finger can result in painful scars or damage to the nerves and vasculature of the distal finger pulp.

The pulp of the fingertip is divided into small compartments by 15 to 20 fibrous septa that run vertically and attach the skin to the periosteum, forming the compartments that serve as the nidus of infection.
Abscess formation in these relatively non-compliant compartments causes significant pain, and the resultant swelling can lead to tissue necrosis.  Because the septa attach to the periosteum of the distal phalanx, spread of infection to the underlying bone can result in osteomyelitis.

1.   When an incision and drainage procedure is performed, it is important to open these compartments to drain the abscess effectively.  There are several techniques for draining felons; however, most practitioners have narrowed it down to two.  These two techniques are thought to be most effective in controlling infection and minimizing the risk of neurovascular injury and painful scar formation:

Felon
Felon

Midvolar technique: images (A and B)

midvolar
Unilateral longitudinal technique: images (C, D and E)

2. Most abscesses point to the middle of the finger pad, making the midvolar approach ideal.  If a sinus tract is present, the incision should include it.  This facilitates complete exposure of the abscess and prevents necrosis of the skin between the incision and the sinus tract.

The incision is made in the midline of the finger pad over the area of maximal swelling and tenderness (distal to the DIP) crease).  The incision should be made long enough to allow drainage of pus and blunt dissection of the compartments of the pulp space, with care taken not to injure the underlying flexor tendon.
The unilateral longitudinal approach is recommended when a sinus tract is not present.  This incision is made on the unopposed of non-border surface of the finger (radial aspect of the thumb and little finger and the ulnar aspect of the index, middle, and ring fingers).  The incision is made 5 mm distal to the DIP crease and just volar to the nail fold, whit is to avoid the neurovascular bundle.  The incision should extend to the subcutaneous tissue, allowing complete drainage of the space.  Blunt dissection just like the midvolar approach is a component of this unilateral longitudinal approach, the goal is to break up the loculations of pus and to explore for foreign bodies, if deemed necessary.

3. After the incision and drainage, area is irrigated thoroughly and packed with sterile gauze.
Antibiotics are given, as previously discussed, and the wound should be reevaluated within 48 hours.
When the patient returns, the gauze is removed, the patient is instructed to soak the wound twice daily and to cover it with dry dressing after each soak; the incision is to heal by secondary intention.  Also, encourage the patient to perform range of motion exercises.

Case Conclusion:
The patient had a Felon, a digital block was performed to provide anesthesia.  Then the area was steriley prepared for incision and drainage.  The thumb was incised using the midvolar approach, drained and thoroughly irrigated in emergency department.  The wound was then packed with sterile gauze, and the patient was educated and sent home with Keflex and follow up in 3 days.

References:
1. Tintinalli Emergency Medicine: A Comprehensive Study Guide, 6th ed: Chapters 44, 268, 269
2. Emergency and Primary Care of the Hand (ACEP Hand Book): Hart, Uehara, Wagner
3. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed: Chapters 46, 47, 48

“Hand Case Discussion” is an educational module that focuses on the diganosis and management of Hand pathology that commonly presents to the Emergency Department.