CURRENT CONCEPTS Acute Hand Infections

Meredith Osterman, MD, Reid Draeger, MD, Peter Stern, MD

CME INFORMATION AND DISCLOSURES

The Review Section of JHS will contain at least 3 clinically relevant articles selected by the Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. editor to be offered for CME in each issue. For CME credit, the participant must read the Technical Requirements for the Online Examination can be found at http://jhandsurg. articles in print or online and correctly answer all related questions through an online org/cme/home. examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx.

The JHS CME Activity fee of $30.00 includes the exam questions/answers only and does not ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure fi include access to the JHS articles referenced. balance, independence, objectivity, and scienti c rigor in all its activities. Disclosures for this Article Statement of Need: This CME activity was developed by the JHS review section editors Editors and review article authors as a convenient education tool to help increase or affirm fl reader’s knowledge. The overall goal of the activity is for participants to evaluate the Ghazi M. Rayan, MD, has no relevant con icts of interest to disclose. appropriateness of clinical data and apply it to their practice and the provision of patient Authors care. All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical bottom of the first page. Education to provide continuing medical education for physicians. Planners AMA PRA Credit Designation: The American Society for Surgery of the Hand designates Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose. The editorial and “ ” this Journal-Based CME activity for a maximum of 2.00 AMA PRA Category 1 Credits . education staff involved with this journal-based CME activity has no relevant conflicts of Physicians should claim only the credit commensurate with the extent of their participation interest to disclose. in the activity. Learning Objectives ASSH Disclaimer: The material presented in this CME activity is made available by the Describe the predisposing factors for acute hand infections. ASSH for educational purposes only. This material is not intended to represent the only List the common microorganisms that cause acute hand infections. methods or the best procedures appropriate for the medical situation(s) discussed, but Appraise the antibiotic management and mode of administration for each acute rather it is intended to present an approach, view, statement, or opinion of the authors hand infection. that may be helpful, or of interest, to other practitioners. Examinees agree to participate Offer surgical treatment strategies for various acute hand infections. in this medical education activity, sponsored by the ASSH, with full knowledge and Discuss treatment outcomes and complications of acute hand infections. awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required Deadline: Each examination purchased in 2014 must be completed by January 31, 2015, to for procedures and drugs that are considered experimental. Instrumentation systems be eligible for CME. A certificate will be issued upon completion of the activity. Estimated discussed or reviewed during this educational activity may not yet have received FDA time to complete each month’s JHS CME activity is up to 2 hours. approval. Copyright ª 2014 by the American Society for Surgery of the Hand. All rights reserved.

The continued emergence of antibiotic-resistant bacteria and the development of only a few new classes of antibiotics over the past 50 years have made the treatment of acute hand in- fections problematic. Prompt diagnosis and treatment are important, because hand stiffness, contractures, and even amputation can result from missed diagnoses or delayed treatment. The most common site of hand infections is subcutaneous tissue and the most common mecha- nism is trauma. An immunocompromised state, intravenous drug abuse, diabetes mellitus, and steroid use all predispose to infections. (J Hand Surg Am. 2014;39(8):1628e1635. Copyright 2014 by the American Society for Surgery of the Hand. All rights reserved.) urn Concepts Current Key words Flexor tenosynovitis, infection, MRSA, necrotizing fasciitis osteomyelitis.

From Mary S. Stern Hand Fellow, Department of Orthopaedic Surgery, University of Cincinnati Corresponding author: Meredith Osterman, MD, Mary S. Stern Hand Fellow, 538 Oak College of Medicine, Cincinnati, OH. Street, Ste. 200, Cincinnati, OH 45219; e-mail: [email protected]. Received for publication March 17, 2014; accepted in revised form March 25, 2014. 0363-5023/14/3908-0035$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.03.031 No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

1628 r 2014 ASSH r Published by Elsevier, Inc. All rights reserved. ACUTE HAND INFECTIONS 1629

REATMENT OF ALL INFECTIONs requires the ini- close, prolonged contact with others (military recruits, tiation of antibiotics. Increased organism re- prison inmates, and homeless individuals).5,6 sistance to antibiotics has complicated this T ’ aspect of patients treatment. Specimens of infected ANTIBIOTICS tissue should be sent for aerobic and anaerobic cul- The choice of antibiotic treatment depends on the tures. If chronic hand infection is suspected, fungal type and severity of infection, host factors, clinical and atypical mycobacterium cultures should be sent presentation, and regional infectious epidemiology. in addition to staining for acid-fast bacteria. Hand The high prevalence of antimicrobial-resistant or- fi fi infections can be super cial or deep. Super cial in- ganisms necessitates initial broad-spectrum antibiotic fections can often be treated with antibiotics alone, coverage. Consultation with the infectious disease except in cases of necrotizing fasciitis, for which team can help and is encouraged, especially in pa- early surgical intervention is imperative. Surgical tients with antimicrobial allergies, immunocom- irrigation and debridement in conjunction with anti- promised states, unusual presentations, or atypical biotic treatment are usually necessary for deep or organisms. severe infections. Short-term splinting is also helpful, Intravenous antibiotics are recommended for bone despite the type or severity of infection. or flexor tendon sheath infection. Septic arthritis re- Prompt diagnosis and early treatment are neces- quires between 1 and 4 weeks of intravenous antibi- sary, because hand function can be compromised otics, and osteomyelitis requires 6 to 8 weeks. with missed diagnoses. The most common site of Oral antibiotics are appropriate for skin or other hand infections is the dorsal subcutaneous tissue and superficial soft tissue infections. The typical course the most common mechanism is trauma, such as e 1 is 14 to 21 days. Trimethoprim sulfamethoxazole penetrating injuries or bites. The virulence of the covers 90% of community acquiredeMRSA and can organism, the local and systemic host factors, and the be used in conjunction with rifampin. Our current anatomical location all have a role in the severity e 2 recommendation is for 2 double-strength trimethoprim and progression of hand infections. An immuno- sulfamethoxazole tablets twice daily. Clindamycin and compromised state, intravenous drug abuse, diabetes fl fi 1 cipro oxacin are also good rst-line agents, especially mellitus, and steroid use all predispose to infections. if the patient has a sulfa allergy, but they have 50% These patients require more operative procedures to and 40% resistance to ca-MRSA, respectively. Once eradicate the infection and are more likely to go on fi 2 cultures con rm methacilin sensitive Saureus,the oral to amputation. Ischemia from microvascular disease regimen can be transitioned to cephalexin or amoxicillin or from trauma disrupts the blood supply to the tis- (Tables 1, 2). sue, preventing host factor bacterial eradication and limiting exposure to antibiotics. CELLULITIS Cellulitis is an infection of the skin and subcutaneous COMMON ORGANISMS tissue without accompanying abscess formation. Pa- Staphylococcus aureus and beta-hemolytic streptococci tients present with an erythematous, swollen, and pain- are the most common bacterial culprits of acute hand ful hand. Associated lymphangitis, when present, may infections.3 Up to 60% of hand infections result from indicate a more severe infection. Presumptive antibiotics to S aureus.1 Although the infectious organism is most should cover the most common causative organisms, often a gram-positive bacteria, gram-negative, myco- Streptococcus pyogenes and S aureus. Although cellu- bacterial, or fungal organisms can also cause chronic litis may occur in any area of the body, hand cellulitis 4 has a higher likelihood of requiring hospital admission infections. Over half are polymicrobial. Patients with 7 infections caused by mixed bacterial flora, often seen in for intravenous antibiotics, to curb the infection. human bite wounds, have the highest complications.4 Bacteria resistance, specifically methicillin-resistant DEEP SPACE INFECTIONS OF THE HAND S aureus (MRSA), is becoming more prevalent both in The deep spaces of the hand include the thenar space, the hospital and community setting. The incidence of hypothenar space, midpalmar space, webspaces, MRSA infections ranges from 34% to 73% of all hand dorsal subaponeurotic space, and Parona space.8,9 3 infections. Risk factors for the development of MRSA Infections in these spaces commonly result from a Current Concepts include prolonged hospitalization, prolonged antimi- puncture wound or spread from a contiguous area. crobial therapy, previous surgical procedures, chronic The mainstays of treatment are incision and drainage illnesses, intravenous drug use, and patients who have in the operating room and appropriate antibiotics.

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TABLE 1. Antibiotic Recommendations for Common Organisms Organism Antibiotic Additional Information

Methicillin-sensitive Cephalexin, amoxicillin clavulanate (orally) Staphylococcus aureus Methicillin-resistant Trimethoprim/sulfamethoxazole (orally), Linezolid: expensive, avoid in S aureus linezolid (orally or IV) endocarditis or meningitis, If sulfa allergy, clindamycin or doxycycline weekly complete blood cell monitoring Vancomycin (IV), daptomycin (IV) Dapto: weekly creatinine Quinupristin/dalfopristin (IV) phosphokinase monitoring Tigecycline (IV) Ceftaroline (IV) Vancomycin-resistant Daptomycin, linezolid (orally or IV), tigecycline (IV), Enterococci quinupristin/dalfopristin (IV) Gram negative Piperacillin/tazobactam Ceftriaxone Ertapenem Quinolones/ciprofloxacin Pseudomonas Piperacillin/tazobactam Cefepime Meropenem Anaerobic infections Ampicillin/sulbactam, Piperacillin/tazobactam, Ertapenem, meropenem Metronidazole Clindamycin Tigecycline Vibrio vulnificus Ceftriaxone and doxycycline Imipenem and doxycycline Nocardia Trimethoprim/sulfamethoxazole 6 mo of treatment in immune- If sulfa allergy: imipenem, ceftriaxone, amikacin suppressed patients Sporothrix schenckii Itraconazole fluconazole and voriconazole Mycobacterium marinum Clarithromycin/azithromycin Trimethoprim/sulfamethoxazole minocycline Ethambutol Aeromonas hydrophilia Ciprofloxacin Imipenem Trimethoprim/sulfamethoxazole Cutaneous anthrax Ciprofloxacin Treatment for 60 d to treat Doxycycline any remaining spores Tularemia Gentamicin and doxycycline

IV, intravenously. urn Concepts Current

Table 3 outlines the anatomic borders of these spaces, introduce bacteria into the area. Patients present with the clinical presentations, and surgical considerations swelling, erythema, tenderness, and abscess forma- for drainage. tion along the nailfold, often extending beneath the nail plate or into the pulp space. The most common organism is S aureus, followed by S pyogenes, PARONYCHIA Pseudomonas pyocyanea, and Proteus vularis.10 Acute paronychia is a soft tissue infection of the Acute paronychia can be treated with warm water lateral nailfold. Minor trauma from nail biting, soaks (with or without povidone or chlorhexidine) hangnails, or manicures inoculate the nailfold and and oral antibiotics.11 If an abscess is present, incision

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TABLE 2. Antibiotic Recommendations for Specific Clinical Scenarios Injury/Organism Antibiotics Duration of Treatment

Suture line abscess Cephalexin or sulfamethoxazole/trimethoprim 7e10 d Abscess Ampicillin/sulbactam þ vancomycin Cefazolin þ vancomycin Clindamycin if severe penicillin allergy Cat or dog bites Amoxicillin/clavulanic acid (orally) or ampicillin/sulbactam (intravenously) 7e14 d If penicillin allergic, ciprofloxacin, ceftriaxone, or doxycycline Human bites Cephalosporins gentamicin and penicillinase-resistant penicillin Osteomyelitis Vancomycin and piperacillin/tazobactam 6e8wk Septic arthritis Vancomycin and piperacillin/tazobactam 3e4wk Tenosynovitis Vancomycin and piperacillin/tazobactam 2e3wk

The antibiotics listed in this chart are first-line antibiotics to be used until cultures dictate treatment.

and drainage are recommended in conjunction with HERPETIC WHITLOW oral antibiotics. We routinely remove all or part of the Herpetic whitlow is a viral infection that can be nail plate. mistaken for a felon, usually affecting the fingertip Chronic paronychia is distinct from acute paro- and caused by herpes simplex virus (HSV) 1 or 2. nychia and is common when hands are constantly Herpes simplex virus 1 is the primary cause in patients exposed to water, such as for dishwashers, swimmers, under age of 10, whereas adults can be infected with and medical professionals. The eponychium becomes either HSV-1 or HSV-2.14 Patients present within rounded and indurated with repeated episodes of in- 2 weeks of viral contact with throbbing pain and flammation and drainage, the nailfold separates from vesicles or bullae containing clear fluid.9 The clinical the nail plate, and the area becomes colonized, often diagnosis can be confirmed with Tzanck smear or with polymicrobial or fungal organisms. This can lead viral cultures. to grooving and thickening of the nail plate. Keeping The virus is self-limiting, often resolving within the area dry, applying antifungal topical creams, and 3 weeks without treatment. The vesicles drain, coalesce, trying oral antifungal or antibiotics is a reasonable first and ulcerate before resolution and are contagious line of attack. Surgical treatment is often required, during the first 2 weeks.14 It is paramount to prevent because topical and oral medications are often un- spreading infection during this time and a dry dressing successful. Eponychial marsupialization is the main- should be worn at all times. Surgical incision and stay of treatment. If nail deformity is present, the nail drainage are contraindicated because a superimposed 12 plate should be removed to help reduce recurrence. bacterial infection can develop. After resolution of the finger lesions, the virus enters into a latency phase and can be retriggered by physiological or psychological FELON stressors.14 The recurrence rate is 20%.15 A felon is an abscess of the digital pulp. The septal compartments of the palmar pad create a closed space HUMAN BITES that can easily form an abscess when inoculated with A human bite (fight bite) initially appears benign but an infectious organism. Patients present with pain, always requires surgical exploration and irrigation. swelling, and a history of penetrating trauma. Treat- The area around the metacarpophalangeal joint is ment consists of oral antibiotics and surgical drai- most often involved and the position of the fingers at nage.13 The most common organism is S aureus, the time of impact contributes to the significance of with MRSA becoming more commonplace. Empiric the injury. A human tooth contacting a clenched fist treatment with antibiotics that cover MRSA is rec- usually violates the extensor tendon and joint capsule 13 ommended until cultures dictate treatment. A lon- and may injure the metacarpal head, inoculating the Current Concepts gitudinal incision from the distal flexion crease to the metacarpophalangeal joint. pulp apex avoids the neurovascular bundles and The human bite injury wound should be surgically permits disruption of the septal compartments. extended, an arthrotomy performed with debridement,

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TABLE 3. Anatomy, Presentation, and Treatment of Deep Hand Space Infections Deep Hand Space Borders Presentation Surgical Points

Dorsal Dorsal: extensor tendons; volar: Dorsal hand swelling and Longitudinal incisions over index subaponeurotic metacarpals and interossei fluctuans and ring metacarpals, not directly over extensor tendons Thenar Dorsal: adductor pollicis; volar: Thenar and first webspace Palmar, dorsal, or 2-incision index flexor tendons; ulnar: swelling, thumb abduction approaches; for pantaloon, septum of Legueu and Juvara; with painful adduction or abscess may drain through radial: adductor pollicis opposition, pantaloon-shaped dual incisions or single insertion at P1 of thumb abscess if involvement of first incision perpendicular to first dorsal webspace through webspace to minimize contiguous spread (Burkhalter) webspace contracture Midpalmar/deep Dorsal: middle and ring finger Loss of normal palmar concavity Transverse incision in distal palmar metacarpals and second and with marked palm tenderness, palmar crease; curvilinear third interossei; volar: flexor painful passive motion of incision along thenar crease tendons and lumbricales; ulnar: middle and ring fingers; hypothenar muscles; radial: substantial dorsal swelling septum of Legueu and Juvara may be present Webspace Subfascial palmar space between Abducted posture of adjacent Must drain both dorsal and volar digits digits with accompanying aspects of abscess; incisions dorsal swelling and volar both dorsally and volarly; tenderness at webspace avoid webspace incisions to prevent contracture Parona Volar: pronator quadratus; Pain with passive finger flexion; Avoid placing incisions directly dorsal: digital flexor tendons; acute carpal tunnel syndrome over flexor tendons or median ulnar: flexor carpi ulnaris; may be present nerve to avoid desiccation radial: flexor pollicis longus

and appropriate cultures obtained. The wound is left common organism found in animal bites, but Staphy- open. Up to 50 species of bacteria reside in the human lococcus, Streptococcus, and anaerobes are also mouth; S aureus and beta-hemolytic streptococci are found.9 Pasteurella species are isolated in 50% of dog the most common.1 Broad-spectrum antibiotics such as bites and 75% of cat bites, but the average bite wound cephalosporins or a combination of gentamicin and a yields 5 variations of bacterial species, with 60% penicillinase-resistant penicillin are the first-line anti- yielding mixed aerobic and anaerobic organisms.18 biotic regimen.16 Tetanus prophylaxis should be administered when Complications such as osteomyelitis, septic arthritis, indicated. deep space infections, and stiffness are common. Fac- Animal bite wounds should be treated with irri- tors contributing to human bite infections include a gation and oral amoxicillineclavulanate or intrave- delay in initial treatment, inadequate initial debride- nous ampicillinesulbactam. If patients are allergic ment, and initial wound closure.17 Patients presenting to penicillin, they can be treated with doxycycline, with bite infections more than 8 days after the initial sulfamethoxazoleetrimethoprim, or a fluoroquinolone injury have an 18% change of requiring amputation.16 plus clindamycin.18 urn Concepts Current

ANIMAL BITES PYOGENIC FLEXOR TENOSYNOVITIS Most commonly, animal bites are from dogs, cats, or In pyogenic flexor tenosynovitis (PFT), bacteria in- rodents.18 Eighty percent are from dog bites, but fect the flexor tendon sheath, between the visceral these rarely result in infections.18 In contrast, cat bites epitenon layer and the outer parietal layer, which is have a 50% infection rate, often requiring admission reinforced by the retinacular pulley system. The sy- and intravenous antibiotics.19 The difference results novial space between the 2 layers becomes distended from the mechanism of the bite; cats have sharp, under pressure and advanced infection can lead to penetrating teeth compared with the crushing, tearing the breakdown of adjacent anatomic barriers. This bite of a dog. Pasteurella multocida is the most can lead to the spread of infection to nearby flexor

J Hand Surg Am. r Vol. 39, August 2014 ACUTE HAND INFECTIONS 1633 sheaths and bursae, and into the forearm through the a lower incidence of amputation (average, 80% normal Parona space. Purulent fluid in the synovial space TAM; 0% amputation rate)21,27 than those with sub- surrounding the tendon denies the tendon vital nu- cutaneous purulence (average, 72% normal TAM; trition, and increased pressure in the infected sheath 8% amputation) and or with both subcutaneous can inhibit blood flow to the tendon, causing necro- purulence and ischemic changes (average, 49% sis.20 Flexor sheath anatomy explains the spread of normal TAM; 59% amputation).21 In addition, delayed infection from the little finger to the thumb (or vice treatment increases the probability of a poor functional versa), through the contiguous palmar radial and ul- outcome.22 nar bursae, causing a horseshoe abscess. Usually, there is a history of penetrating trauma to the digit before presentation. Although no studies have NECROTIZING FASCIITIS validated their sensitivity and specificity, Kanavel’s Necrotizing fasciitis is a medical emergency. Ag- 4 cardinal signs remain helpful in diagnosing PFT. gressive, urgent surgical intervention is of utmost These signs, listed in descending frequency, include importance. Delay in diagnosis can lead to loss of fusiform digital swelling (usually associated with life or limb. The infection involves the fascia and erythema), pain with passive digital extension, semi- subcutaneous tissue, sparing underlying tissues. Two flexed digital posture, and tenderness along the fle- types have been described. Type 1 is most common, xor tendon sheath with frequent extension into the caused by mixed aerobic and anaerobic organisms palm.21 The presence of all 4 Kanavel signs occurred and frequent in immunocompromised hosts.28,29 Type in only 54% of PFT patients in 1 series.22 Laboratory 2 results from group A Streptococcus and/or Staphy- values such as white blood cell count, erythrocyte lococcus organisms and more typically affects the sedimentation rate, and C-reactive protein can be extremities.28 Risk factors include immunosuppres- helpful in confirming the diagnosis of PFT.23 Ele- sion, peripheral vascular disease, diabetes mellitus, vation of at least 1 of these markers, in combination chronic liver disease, and intravenous drug abuse.28,29 with clinical evaluation, was 100% specific in iden- Initially, these infections can appear as low-grade tifying cases of PFT. However, sensitivities of these cellulitis. Clinical signs more indicative of necro- markers were low (white blood cell, 39%; erythrocyte tizing fasciitis include crepitus, fluctuans, nonpitting sedimentation rate, 41%; and C-reactive protein, 76%), edema, tenderness beyond areas of erythema, hypo- indicating that markers were not always elevated in the tension, fever, and tachycardia.29 Vascular throm- setting of PFT.23 bosis leads to skin sloughing, blistering, ischemia, Treatment for PFT is surgical irrigation of the flexor and resultant necrosis.28 sheath and intravenous antibiotic therapy. The most Upon surgical debridement, the fat appears gray common organisms include S aureus and Strepto- and liquefied with a “dishwater pus” appearance. coccus species; thus, antibiotics before culture data Frank pus is uncommon. Malodorous tissue is com- e should cover these bacteria.22 24 For severe infections mon with anaerobic organism involvement.28 Char- with subcutaneous purulence or necrotic tendon, open acteristically, the skin and subcutaneous tissue are exposure of the sheath and irrigation of the sheath elevated from the fascia, necessitating extensive through windows sparing the A2 and A4 pulleys is debridement to healthy tissue.28 Operative cultures necessary. A midaxial approach is preferred over a are taken, the wounds are left open, and debridement Bruner incision, which can lead to postoperative is repeated every 24 to 48 hours as needed. Initial tendon exposure or peri-incisional skin loss.25 Limited treatment includes broad-spectrum intravenous anti- exposure of the sheath with closed catheter irrigation is biotics that cover aerobes and anaerobes and often favored in the absence of loculated purulence. It allows require multiple drugs simultaneously. A reasonable for minimization of trauma to the digit and pulley combination includes ampicillinesulbactam, clinda- system and has been shown to result in equivalent mycin, and ciprofloxacin.18 Amputation may be ne- outcomes to open irrigation of the sheath.22,26 cessary to control the infection but does not reduce Factors responsible for a poor outcome or risk mortality rates.29 of amputation include age greater than 43 years, Mortality rates range from 23% to 76%; organ certain comorbidities (diabetes mellitus, renal failure, failure and sepsis are the major causes of death.30 or peripheral vascular disease), subcutaneous puru- Delay in diagnosis and delay in surgical debridement Current Concepts lence, and ischemic changes upon presentation.22 are significantly associated with increased mortality.29 Digits without subcutaneous purulence or ischemic Advanced age and 2 or more comorbidities further changes regain more total active motion (TAM) with increase mortality rates.29

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SEPTIC ARTHRITIS the severity of contamination contribute to its deve- Septic arthritis of the joints of the hand is commonly lopment. Staphylococcus aureus and Streptococcus caused by penetrating trauma or the spread of infection are the most common causative organisms. Gram- from contiguous structures. Like other closed space negative bacteria, anaerobes and atypical and fungal infections, bacterial toxins and local inflammatory organisms can also lead to osteomyelitis, and a mixed response result in the majority of damage to the bacterial etiology is common in patients with vascu- 38 joint.31,32 The most common organisms are beta- lar insufficiency or an immunocompromised state. hemolytic Streptococcus and S aureus. Neisseria Mixed bacterial infection predisposes the patient to 38 gonorrhoeae should be considered in sexually active the high likelihood of amputation. Hardware and patients, whereas Haemophilus influenza should be other devitalized tissue are a nidus for bacterial considered in unvaccinated children. Examination re- inoculation, most commonly S epidermis, and must veals fusiform joint erythema and swelling and pain be removed to eradicate infection. with active or passive motion. Joint aspiration allows The distal phalanx is the most commonly affected 38 for definitive diagnosis, and in addition to cultures and in the hand. Osteolysis and soft tissue swelling are cell count, crystal analysis should be performed the most common radiographic findings. Periosteal because crystalline arthropathies, particularly gout, new bone formation, involucrum, and sequestrum are can present with a similar picture. less common in the tubular bones of the hand. A Classically, a cell count of 50,000 with greater definitive diagnosis requires a bone biopsy and cul- than 75% polymorphonuclear leukocytes and glucose tures. Treatment consists of intravenous antibiotics of 40 mg% less than fasting blood glucose level was and operative debridement. Intravenous antibiotics 39 consistent with a diagnosis of septic arthritis. More are instituted for a minimum of 4 to 6 weeks. recent studies have demonstrated that lowering the cell count threshold to 17,500 increases the sensi- REFERENCES tivity of the diagnosis of septic arthritis to 83%, with 33,34 1. Houshian S, Seyedipour S, Wedderkopp N. Epidemiology of bacte- an acceptable specificity of 67%. rial hand infections. Int J Infect Dis. 2006;10(4):315e319. Treatment of septic arthritis involves irrigation and 2. Ong Y, Levin LS. Hand infections. Plast Reconstr Surg. 2009; debridement of the joint and systemic antibiotics. 124(4):225e233. 3. Tosti R, Ilyas A. Empiric antibiotics for acute infections of the hand. A recent study found that after surgical drainage, a J Hand Surg Am. 2010;35(1):125e128. short course of intravenous antibiotics of less than 4. 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Volz KA, Canham L, Kaplan E, Sanchez LD, Shapiro NI, outcomes compared with open procedures.36 Meta- Grossman SA. Identifying patients with cellulitis who are likely to require inpatient admission after a stay in an ED observation unit. Am carpophalangeal joints should be entered through a J Emerg Med. 2013;31(2):360e364. longitudinal, dorsal incision, with at least partial 8. Burkhalter WE. Deep space infections. Hand Clin. 1989;5(4):53e59. preservation of the sagittal bands to avoid post- 9. Franko O, Abrams R. Hand infections. Orthop Clin N Am. 2013; 44(4):625e634. operative extensor tendon subluxation. Interphalan- 10. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. geal joints should be approached through a midaxial 2001;63(6):1113e1116. urn Concepts Current incision between the volar plate and the accessory 11. Ritting AW, O’Malley MP, Rodner CM. Acute paronychia. J Hand Surg Am. 2012;37(5):1068e1070. collateral ligament, or between the lateral slip of the 12. 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JOURNAL CME QUESTIONS

Acute Hand Infections What percentages of Pasteurella species are isolated from dog and cat bites? Which of the following microorganisms are most a. 10% of dog bites and 35% of cat bites sensitive to ciprofloxacin? b. 20% of dog bites and 45% of cat bites a. Anthrax and Aeromonas hydrophilia c. 30% of dog bites and 55% of cat bites b. Norcardia and tularemia d. 40% of dog bites and 65% of cat bites c. Mycobacterium and Vibrio e. 50% of dog bites and 75% of cat bites d. Pseudomonas and Sporothrix e. MRSA and all viruses

To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home. Current Concepts

J Hand Surg Am. r Vol. 39, August 2014