Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

343. Surgical Treatment of Deep Space Infections of the Hand

Eric Stuffmann and Jeffrey Yao

DEFINITION

images Deep space infections occur in one of three anatomically defined potential spaces within the hand—the thenar, midpalmar, and hypothenar spaces—or in one forearm potential space, Parona’s space.

images Thenar space infections are the most common deep space infections. Midpalmar and hypothenar space infections are much more rare.

images Deep space infections usually result from direct penetrating trauma or spread from an adjacent infection such as a superficial abscess or a flexor tenosynovitis (in the case of thenar and midpalmar space infections).

images The single most common infecting organism is Staphylococcus aureus, although most of these infections are mixed.

ANATOMY

images The thenar space (FIG 1) is defined by the fascia of the adductor pollicis muscle dorsally and the tendon sheath of the index finger and palmar fascia volarly.

images The radial border is defined by the insertion of the adductor pollicis tendon and fascia on the thumb proximal phalanx.

images The ulnar border is the midpalmar (oblique) septum, which extends from the third metacarpal to the palmar fascia.

images The midpalmar space (see FIG 1) is bordered radially by the midpalmar septum and bordered ulnarly by the hypothenar septum, which extends from the fifth metacarpal to the palmar fascia.

images The dorsal border of the midpalmar space is the fascia of the second and third palmar interosseous muscles, and the volar border is the flexor sheaths of the long, ring, and small fingers and the palmar fascia.

images

FIG 1  Cross-sectional anatomy of the hand demonstrating the deep spaces.

images The hypothenar space (FIG 1) is bordered radially by the hypothenar septum and dorsally by the periosteum of the fifth metacarpal. The fascia of the hypothenar muscles forms the ulnar and palmar borders.

images Parona’s space is a deep potential space in the distal forearm superficial to pronator quadratus and deep to the flexor digitorum profundus tendons. It is continuous with the midpalmar space.

PATHOGENESIS

images Thenar space infections may result from penetrating injury or local spread from adjacent flexor tenosynovitis or a subcutaneous abscess.

images If not treated early, the infection may spread to the dorsal side of the hand after destroying the fascia of the adductor pollicis muscles and traveling between the transverse and oblique heads.

images Midpalmar space infections usually result from direct penetrating trauma, but may also result from spread of an adjacent flexor tenosynovitis or superficial abscess.

images Hypothenar space infections usually result from direct penetrating trauma, but may also result from spread of a superficial abscess.

images Parona’s space infection may result from direct penetrating trauma, in which case the infection may be isolated to Parona’s space.

images Infection involving Parona’s space may also result from contiguous spread from a ruptured radial or ulnar bursae (FIG 2). The end result will be involvement of the midpalmer space and a horseshoe abscess (FIG 3).

images

FIG 2  Radial and ulnar bursae may communicate in the distal volar forearm (Parona’s space).

images

FIG 3  Drawing representing the clinical appearance of a horseshoe abscess.

PATIENT HISTORY AND PHYSICAL FINDINGS

images The patient may recall a history of a penetrating injury in the vicinity of the involved deep space.

images In the case of a thenar space infection, the patient will present with swelling and tenderness in the thenar region.

images The patient will hold the thumb in an abducted position to minimize the pressure for comfort.

images If the infection has been present for some time, it may have spread dorsally, in which case swelling and tenderness will be found dorsally in the first web space.

images In the case of a midpalmar space infection there will be tenderness and swelling in the midpalm, although dorsal swelling may be more impressive due to the strength of the palmar aponeurosis.

images The fingers will be held in a semiflexed posture.

images This condition is distinguished from flexor tenosynovitis by relative lack of pain with passive motion of the fingers and with direct palpation of the flexor sheath along the digit.

images Infection of Parona’s space is characterized by swelling in the distal volar forearm and pain with digital flexion.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Radiographs should be obtained in all cases to rule out the presence of foreign bodies.

images Radiographs also may reveal underlying osteomyelitis in the setting of more chronic infections.

images Patients suspected to have systemic illness should have an appropriate laboratory workup.

DIFFERENTIAL DIAGNOSIS

images Thenar space infection

images Midpalmar space infection

images Hypothenar space infection

images Flexor tenosynovitis

images Superficial abscess

images Osteomyelitis

NONOPERATIVE MANAGEMENT

images There is no role for nonoperative treatment in the setting of deep space infections.

images Antibiotics should be avoided until adequate cultures can be obtained, unless the patient is systemically ill and there will be a forced delay in operative treatment.

SURGICAL MANAGEMENT

images Drainage of deep space infections should be carried out in the operating room under general anesthesia.

images Gram stain and cultures for aerobes, anaerobes, mycobacteria, and fungi should be obtained intraoperatively just before IV antibiotics are administered.

images Thorough irrigation with 6 to 9 L of normal saline should be performed.

images All nonviable tissue must be débrided sharply.

images Surgical wounds may be closed very loosely over a drain if all necrotic tissue has been thoroughly débrided.

images If there is any doubt, the wound should be left open to heal by secondary intention using wet-to-dry dressing changes and soaks.

images In very severe cases, a second irrigation 48 to 72 hours later may be required.

Positioning

images The patient is positioned supine with a standard hand table and nonsterile tourniquet.

Approach

images Drainage of thenar space infections can be performed through a volar incision or a dorsal longitudinal incision (or, sometimes, both).

images A volar incision involves risk to the recurrent motor branch of the median nerve, the digital nerves to the thumb and index finger, the princeps pollicis artery, and the proper digital arteries.

images A volar incision also allows concomitant treatment of a thumb septic flexor tenosynovitis.

images A dorsal longitudinal incision avoids the painful scar associated with a volar incision.

images Drainage of midpalmar space infections may be performed through a transverse skin incision in, or parallel to, the distal palmar crease over the third and fourth metacarpals.

images Alternatively, a curved longitudinal incision may be used.

images Hypothenar space infections are approached through an incision in line with the ulnar border of the ring finger extending from 3 cm distal to the wrist crease to just proximal to the midpalmar crease.

images Parona’s space may be approached through a longitudinal incision just ulnar to the palmaris longus.

images Alternatively, a trans–flexor carpi radialis approach may be used. Parona’s space

TECHNIQUES

INCISION AND DRAINAGE OF THENAR SPACE INFECTIONS

images  In the case of a volar approach, make an incision just adjacent and parallel to the thenar crease, beginning 1 cm proximal to the web space and extending 3 to 4 cm proximally (TECH FIG 1A).

images  After blunt dissection through the palmar fascia, the digital nerves to the thumb and index finger, the princeps pollicis artery, the proper digital arteries, and the recurrent motor branch of the median nerve are encountered (TECH FIG 1B,C).

images  The abscess will lie superficial to the adductor pollicis muscle.

images  Dissection should then continue dorsally over the distal edge of the adductor muscle to decompress any dorsal extension of the abscess.

images  Alternatively, a thenar space infection may be approached dorsally through a longitudinal incision (TECH FIG 1D).

images  The dorsal incision may be straight or slightly curved and should bisect the space between the first and second metacarpals.

images Dissection should be carried down to the interval between the first dorsal interosseous muscle and adductor pollicis muscle, where the purulence will be encountered.

images  Thoroughly débride all necrotic tissue, and irrigate copiously with sterile saline.

images  Place a strip of packing strip gauze into the open wound to allow for drainage, and dress the wound appropriately.

images

TECH FIG 1  A. Thenar incision. B,C. Neurovascular bundle. D. Alternative dorsal incision for drainage of thenar abscess.

INCISION AND DRAINAGE OF MIDPALMAR SPACE INFECTIONS

images  Make a transverse incision parallel to or in the distal palmar crease over the third and fourth metacarpals (TECH FIG 2A).

images Alternatively, a curved longitudinal incision may be used (TECH FIG 2B).

images  Bluntly dissect to either side of the flexor tendons to the ring or middle finger, where the abscess will be encountered.

images  Protect the neurovascular bundles, which lie on either side of the tendons (TECH FIG 2C).

images  Thoroughly débride all necrotic tissue, and irrigate copiously with sterile saline.

images  Place a strip of packing strip gauze into the open wound to allow for drainage, and dress the wound appropriately.

images

TECH FIG 2  A. Transverse incision for drainage of midpalmar abscess. B. Curved longitudinal incision for drainage of midpalmar abscess. C. Drainage of midplanar abscess (neurovascular bundle protected by freer).

INCISION AND DRAINAGE OF HYPOTHENAR SPACE INFECTIONS

images  Make an incision in line with the ulnar border of the ring finger extending from just proximal to the midpalmar crease to 3 cm distal to the wrist crease (TECH FIG 3A).

images  Incise the hypothenar fascia in line with the skin incision, and the purulence will be encountered (TECH FIG 3B).

images  Thoroughly débride all necrotic tissue, and irrigate copiously with sterile saline.

images  Place a strip of packing strip gauze into the open wound to allow for drainage, and dress the wound appropriately.

images

TECH FIG 3  Incision (A) and drainage (B) of a hypothenar abscess.

INCISION AND DRAINAGE OF PARONA’S SPACE INFECTIONS

images  Approach Parona’s space with a longitudinal incision in the distal forearm just ulnar to the palmaris longus.

images  If the infection is isolated to Parona’s space, keep the incision proximal to the wrist flexion crease.

images  If the infection is contiguous with a midpalmar space abscess, the incision is carried across the wrist in Brunner fashion.

images

POSTOPERATIVE CARE

images Intravenous antibiotics, initially given intraoperatively, are continued postoperatively.

images The patient may be switched to oral antibiotics once cultures and sensitivities return from the microbiology laboratory and if he or she is responding to IV antibiotic therapy.

images Let open wounds heal by secondary intention using wet-todry dressing changes and soaks or whirlpools.

images Remove drains after 24 to 48 hours, depending on the condition of the wound and particulars associated with surgery.

images Begin early range-of-motion exercises during soaks or whirlpool treatments to minimize digital stiffness.

images Treatment of systemic illness is critical.

COMPLICATIONS

images Persistent abscess formation if irrigation and débridement is inadequate or the wound is closed tightly and not allowed to drain

images Systemic spread of the infection if appropriate treatment is delayed

SUGGESTED READING

Burkhalter WE. Deep space infections. Hand Clin 1989;5:553–559. Hausman MR, Lisser SP. Hand infections. Orthop Clin North Am 1992;23:171–185.

Leddy JP. Infections of the upper extremity. J Hand Surg Am 1986;11:294–297.

Siegel DB, Gelberman RH. Infections of the hand. Orthop Clin North Am 1988;19:779–789.



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!