Infections to the hand are common occurrences because our need to use our hands for all activities. A hand infection can be seeded by a direct penetrating injury that breaches the skin or arise from another infected part of the body, travelling though our blood stream.
Infections can are subdivided into superficial or deep, localized or diffuse, fluctuant (soft center) and indurated (firm consistency). If the infection is not interrupted by active intervention, destruction of the tissues ensue progressing rapidly and possibly leading to death if unattended. Infections are like a cancer, but with infections, the advancement is much faster and more destructive. The severity of the infection depends on the aggressiveness of the micro-organism, the ability of the patient to mount an appropriate response against the infection and the amount of bugs received during the contamination as well as other factors from the environment. In general, patients with diabetes, cancer, HIV, Hepatitis, those receiving chemotherapy or other immunosuppressant drugs who cannot mount a normal response to infections are at risk. Infections can be acute or chronic. Chronic infections have a more prolongued course and are indolent and less evident when first affected. The mycobacterium or fungi are frequently the cause of chronic infections. Acute infections are easily recognized as symptoms are more abrupt in presentation with patients complaining of pain, redness, warm and swelling in the area of interest. Red striking up to the forearm or shoulder may be present. Patients may also experience fever, chills and generalized discomfort. Diffuse superficial infections are called cellulitis and invade the subcutaneous tissue. They are treated in the early phases with warm compresses, antibiotics (more reliably administered by the vein) hand elevation, and closed monitoring. Admission to the hospital will depend on the severity of the infection and the systemic findings.
Localized infections present with pain and induration (hard swelling) that becomes fluctuant (soft) forming an abscess where a pocket of pus is walled off. Once an abscess is present, treatment is prompt surgical debridement (cleaning) with culturing the site prior to administering antibiotics is preferred. Sometimes a patient may need several trips to the operating room for serial debridement. Appropriate debridement combined with the correct antibiotic should resolve most cases. The most frequent organisms causing infections are the skin flora of Staphylococcus Aureous and Streptococcus. The organisms are similar but their susceptibility to antibiotic treatment has changed with the emergence of resistant strains like MRSA ( Methicillin Resistant Staphylococcus Aureous). Careful selection of final antibiotic treatment according to the cultures is critical and the consultation with Infectious Disease specialist may be required. Joint infections are more critical for their ability to quickly destroy the joint leaving permanent damage. X rays and joint aspiration assists in the diagnosis. Early diagnosis and treatment is critical for a successful outcome. There are conditions that can closely mimic infections like gout and pseudo gout which is a crystal deposition disease. These are not infections but may also require surgical treatment to clean out a joint or tendon since, like infections, induce an inflammatory response that is destructive to tissues.
A special consideration should be made for a very aggressive form of infection named Necrotizing Fasciitis. It can be fatal when treated inappropriately or insufficiently. Necrotizing Fasciitis is the most rapidly advancing infection travelling through the facial planes and leaving tissue destruction throughout its course. Symptoms include pain, fever and chills. This infection is more frequently seen in immunocompromissed patients. The initial symptoms can be just localized pain and minimal swelling, induration and redness progressing to lymphangitis (red striking), decrease motion, peeling of skin, severe tenderness, fever, chills and blistering ( a late sign). Crepitance of the soft tissues (a crunchy feeling under the skin) may be present when the infective organism forms gas. The responsible microorganisms are frequently anaerobic, streptococci, vibrio and clostridium as single organisms or in combination. A high index of suspicion and experience recognizing this potentially lethal condition is key for diagnosis and to abort the morbidity and mortality associated with this condition. Your surgeon at ROC should be emergently contacted if this condition is suspected. The hallmark of treatment is radical surgical removal of infected tissue and sometimes amputation to save the patient’s life.