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Baghdad College of Medicine / 5

th

 grade 

Student’s Name :  

 

 

Dr. Ahmed Khalaf 
Lec. 2 

Hand Examination & 
Infection 

Wed. 4 / 10 / 2016

 

 

 

DONE BY : Ali Kareem 

مكتب اشور لالستنساخ

 

2016 – 2017  


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

4-10-2016

 

 

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©Ali Kareem 2016-2017 

 

Hand Examination & Infection 

 

Hand : 

Mechanical device with receptors  that can produce powerful, delicate and fine movements. The 
requirement for the hand function:

 

1-  Good skin coverage with intact sensation.

 

2-  Supple joints and mobile fingers.

 

3-  Pain free movements and with good tendon excursion.

 

4-  Coordination 

 

Functions of hand : 

1-  Fine pinch,  e.g. picking up a small object . 
2-  Power grip, e.g. holding a hammer . 
3-  Key grip, e.g. holding a key . 
4-  Chuck grip, holding a pen . 
5-  Hook grip, e.g. carrying a suitcase .  

 

History: 

The patient age, hand dominance, occupation and history of prior upper extremities problem are 
obtained.

 

For traumatic injury ask about the following :

 

1-  When? How much time has elapsed since injury?  

Contamination usually low in 1

st

  6 hours after injury.

 

2-  Where? What was the environment at site of injury? 

Whether clean or dirty environment.

 

3-  How? 

Mechanism of injury whether clear cut or crushing injury.

 

Position of hand or finger at time of injury (fall on outstretch hand or whether hand was open or 
grasping)

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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4-  Previuos treatment which was given and tetanus immunization status?

 

5-  Any associated injury?

 

 

Physical examination: 

  Look:  

 

Skin: For any cuts, haematoma, swelling, bruise, nail, also look for tight Bands in palm leading 
up to fingers (Duputyren contracture). 

 

 

 

 

Soft tissues : Check for thenar and hypothenar wasting, also check for wasting in cleft between 
fingers dorsally (damage to ulnar nerve or T1) 

 

 

 

 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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Circulation : pallor of finger indicate arterial insufficiency or anaemia. ischaemic atrophy of the 
pulp of fingers make the finger thin and pointed. 

 

Bone : Look for any bone malialigmant. 

 

for swan neck deformity (hyperextension in middle IP joint

 

 With flexion of distal IP joint).

 

 

 

 

 

 

Look  for Boutonniere deformity (hyperextension at distal IP joint With flexion at middle IP 
joint). 

 

 

 

 

 Also look for Heberden nodule over the DIP joint dorsally which associated with osteoarthritis, 
or Garrod knuckle pad over PIP dorsally.

 

 

 

 

 

 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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Feel :   

 

  Skin: feel for loss sensation or altered sensation by (cotton wick, pin Test, 2 point 
discrimination) along median, ulnar, radial nerve distribution

 

 

 

 

 

 

 

 

  

 

 

 

Soft tissues: feel for wasting of  thenar and hypothenar muscles.                   

 

Circulation: feel the temperature of skin. Feel radail and ulnar pulses at the wrist. Also feel for 
capillary refilling.

 

Allen`s test: ask the patient to clench one fist tightly and then compress the ulnar and radial 
arteries at wrist with your thumb. After 10 seconds, ask the patient to open hand. The palm will 
be white. Reales the compression on the radial artery and watch the bloood flow into the hand, 
repeated the procedure on the ulnar artery.

 

 

Allen test  

 

 

 

 

 

 

 

 

 

 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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Bone: feel for any swelling, tenderness.

 

 

Move: 

Active: ask patient to roll finger from full extension to full flexion .test Flexion of MCP joint in 
isolation while keeping PIP joint and DIP joint extended. this test patient ability to intrinsic 
muscles movement. Also test abduction and adduction of fingers. 

 

Passive: Passively move the joints to see the range of movement, Pain in movement, and 
unstable joints 

 

Flexor tendon examination:  

There are 4 methods for examination:

 

1-   active motion:

 

o  by blocking all joints in single digit and allow only distal interphalangeal (DIP) flexion, 

one can examine flexor digitorum profundus (FDP). 

 

 

 

 

o  by holding all digit in extension except in digit to be examine, and ask patient to flex 

proxiaml interphalangeal joint (PIP), one can examine flexor digitorum supeficialis 
(FDS)

 

    

 

 

 

2-  observation at rest: 

See the cascade of digit at rest ,normally there is progression of increasing flexion from index to 
little finger. Extended position of digit mean suspected flexor tendon injury. 

 

 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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3-  tenodesis effect:

 

The wrist moved from flexion to extension passively, normal function is demonstrated by the 
finger curling into flexion with wrist extension and should be extended (open) with wrist flexion

 

 

4-  squeeze test: 

Can result in flexion of intact tendon.

 

 

Extensor tendon examination: 

1-  active motion:

 

Placing hand flat on table and ask patient to lift each finger from table. Test is done against light 
resistance from examiner hand.

 

2-  observation at rest:

 

With extensor tendon injury we see the finger slightly more 

flexed than other normal digit.

 

3-  tenodesis effect.

 

 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

4-10-2016

 

 

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Investigation: 

o  Plain x-ray
o  E.M.G 
o  Ultrasound 
o  Doppler ultrasound 
o  Angiography 
o  Radioistope study 
o  Arthroscope. 
o  CT/SCAN 
o  MRI 

 

General principles of management of hand infection: 

If hand infection are not treated promptly, tendon adhesion, necrosis and even repture, stiffness, 
and loss of function will ensue.

 

In summery:

 

 Trauma ,Infection →swelling →ligament adhesion and contracture →loss of function 

 

 

 

 

 

 

1-  Rest: resting an infecting part minimizes the opening of tissue plane along which it can 

spread and the breaking down of barriers which is important for wall off the infection. 

2-  Splinting : when we need to immobilize hand it should be putting in (safe position) this 

keep ligament under maximum stretch to prevent their shortening and subsequent 
restriction of joint mobility. 

 

Safe position: IP joint extension, MCP joint flexion and 

Palmer abduction of thumb and slight wrist extension.

 

 

 

 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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3-  Elevation: of hand above the level of the heart so encouraging venous and lymphatic 

return , which is minimizes edema due to the inflammatory reaction and poor muscular 
activity which is due to pain and therapeutic rest. 

The point of reference for elevation of the part is its relation to right atrium of heart.

 

 

 

 

 

4-  heat application: the application of heat increase the delivery of inflammatory cells to 

affected area by vasodiltation, and laso improve patient comfort. Moist heat more 
effective than dry heat. Frequent seperated application are recommended rather than 
attempting to do it continuously.

 

5-  movement and rehabilitation : because prolonged immobilization can lead to stiffness of 

small joints, immobilization should be maintained where essential for minimal time while 
continued movement of other parts is encourages. 

 

6-  antibiotics: in all cases , initial antibiotic selection has to be on a (best guess). The 

majority of hand infection are due to staphylococcal and streptococcal bacteria, with 
anaerobic bacteria being relatively rare. Therefore, it is recommended that for ordinary 
caese , a penicillinase resistance antibiotic such as 1

st

 generation cephalosporin, which 

may combined with antistaph penicillin, be used. Antibiotic change later according to 
result of culture and sensivity test. 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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7-  surgical drainage: any abscess or necrotic tissues that can be positively identified, it 

should be surgically drained and specimen for bacterial studies should be taken. 

 

Hand infection: 

may involved skin, subcutaneous tissue, tendon sheath, joints and bone and may be caused by 
wide of vraiety of pathogens, including viruses,bacterai,mycobacteria and fungi. 
Three major factors contribute to development of infection in hand: 
1- the infecting organism 
2- the anatomic location of the infected space. 
3- systemic and local host defense factors. 

 

Specific infection:

 

1-  Cellulitis  and  lymphangitis:  all  hand  infection  is  begin  as  cellulitis.  cellulitis  is  non-

supporative  superficial    infection  of  skin.  there  is  poor  localization  in  addition  to  the 
cardinal  sign  of  inflammation  i.e.  redness,hotness,swollen,pain  and  tendrness.usaully 
caused  by  B  hemolytic  streptococci,  staphylococci  and  c.perfringens.tissue 
destruction,gangene and ulceration may follow ,which are caused by release of protease. 
Systemic  sign  and  symptoms  like  fever,chill,tachycardia  follow  the  realese  of  exotoxine 
and cytokines into circulation.  
Cellulitis is usually located at the point of injury and subsequent tissue infection.

 

 

 

 

 

 

Lymphangitis is part of a similar process and present in painful red streak in affected lymphatic 
usually accompanied by painful lymph node groups in the related drainage area. 

 

 

 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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The vast majority of cases will respond to oral antibiotics, rest, warm soaks and elevation. 

Because gram positive organism are typically responsible, first generation cephalosporin or  
antistaph penicillin is appropriate e.g. flucloxacillin.

 

 

2-  Acute paronychia: this is the most common infection of the hand, it is infection of the soft 

tissues alongside the nail plate. this is typically result from inoculation of bacterium 
between the nail and surrounding tissues, often as consequence of relative minor trauma 
such as nail biting, hangnail, puncture wound, foreign body and manicure. 
S.aureus is the most common isolate bacteria, but anaerobes are frequently present and 
attributed to contamination of the wound with oral secretion. Usually presented with 
pain, erythema and oedema of tissues surrounding the nail, later on if no treated abscess 
may be formed. 
An infection that  involves the proximal nail and one lateral fold known as eponychia

 

When the abscess dissects under the nail sulcus to the opposite lateral fold know as run around 
abscess. Confined collection of pus can place presure on germinal matrix, resulting in nail 
deformity. 

 

Treatment: if the paronychia diagnosed at an early stage before abscess formed, oral 
antibiotics, warm soak, rest, and elevation may be sufficient treatment. 

For abscess localized to one lateral fold , the fold can be elevated bluntly by Freer elevator or 
blade can be used.

 

 

 

 

 

 

 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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For treatment of eponychia : two incision are made at the edge of nail fold, the proximal nail is 
excised , and the fold is elevated and packed with guaze. 

Rarely, the pus collection will elevated entire nail plate, which need at that time removal of nail 
plate.

 

 

 

 

 

3-  Chronic paronychia: A paronychia may present as a chronic process, with an indurated, 

erythematous eponychium (proximal nail fold)and occasional drainage from the nail fold 
and longitudenal grrove in the nail plate. This occurs more frequently in diabetic patients 
and in those with frequent occupational exposure to a moist environment, such as food 
service handlers with frequent immersion of the hands in water. Candida albicans is the 
most common pathogen responsible. 

 

Treatment: it may resolve if the hands are kept dry and the nail fold are regularly 
dressed with  topical antifungal e.g. clotrimazole and steroid.

 

Removal of a thickened  , deformed nail plate may be improve the result.

 

If all are failed , eponychial marsupialization is done, where a crescent-shaped portion of the 
skin overlying the proximal nail bed is excised , with removal of all granulation tissues down to 
germinal matrix. The wound is leave to healed by secondary intention.

 

 

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

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4-  Flon : A felon is an abscess of the distal pulp of the thumb or finger. Because of the 

unique anatomy of the pulp, with 15 to 20 longitudinal septa anchoring the skin to the 
distal phalanx, the pulp is divided into multiple closed compartments. Abscess formation 
within these small closed compartments results in rapid development of swelling and 
throbbing pain. The pain is usually worsened by dependency, and may keep the patient 
from sleeping at night. 

Felons typically present after a history of a puncture wound, thus radiographs should be 
examined carefully for evidence of  retained foreign body.

 

The most common pathogen involved is S. aureus

 

Complications of untreated or inappropriately treated felon: 

1-  painful , unstable , insensate , unaesthetic scar.

 

2-  acute flexor tenosynovitis

 

3-  septic arthritis.

 

4-  osteomylitites.

 

5-  deep space infection.

 

6-  amputation.

 

Treatment: Early felons may resolve with oral antibiotics, warm soaks, rest, and elevation; 
however, any sign of fluctuance requires surgical drainage. A variety of incisions have been 
described for the drainage of felons.

 

If the abscess is pointing, the preferred approach is a longitudinal volar incision through the tip 
of the abscess, and should not cross the DIP crease.

 

 

 

 

 

 

 

Alternatively, a longitudinal incision is made just dorsal to the midlateral line, and may be 
extended around the tip of the finger in a “hockey stick” fashion for extensive felons

 

 

 

 


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5-  Bacterial flexor tenosynovitis: synovial sheath that surrounding index , middle and ring 

finger extended from DIP to MCP. In thumb has a sheath from IPJ through a radial 
bursa into the distal forearm. The little finger synovial sheath extended from DIP to large 
ulnar bursa which surronded the FDS and FDP tendons of all four digits from midpalm 
proximally to proximal margin of pronator quadratus. In 80% there is interconnection 
between radial and ulnar bursa in palm.  

Flexor tenosynovitis is a surgical emergency as the pressure and pus in tendon sheath 
cause ischaemic necrosis of the tendon, leading to rupture. In lesser state the tendon 
rapidly adhere to its sheath result in permenant stiffness. The cause is penetrating injury 
of flexor tendon at level of DIP and PIP. The injury may be not noted  by patient. 

The ring , middle, and index finger are the most commonly affected, and S. aureus is the 
most common isolate.

 

 

Kanavel described the four cardinal signs of flexor tenosynovitis that bear his name:  

A.  fusiform swelling of the finger 
B.  partially flexed posture of the digit 
C.  tenderness over the entire flexor tendon sheath 
D.  disproportionate pain on passive extension 

 

 The latter sign is the most constant and typically the first present in early cases.

 

Treatment: 

Early cases of flexor tenosynovitis (i.e., less than 48 hours ) may respond to conservative 
management, including intravenous antibiotics, rest, heat, and elevation.

 

Failure to respond within 24 to 48 hours warrants immediate operative intervention.

 

Less severe cases of flexor tenosynovitis may be treated with a limited 

 

incision and catheter irrigation technique (close method). A transverse incision is made 

 

 

 


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just distal to the distal flexion crease. A similar incision is made in the palm over the proximal 
edge of the A-1 pulley The sheath is copiously irrigated with sterile normal saline.

 

 

 

 

 

 

 

 

For severe cases, zigzag fashion incision is made over the entire course  

of the flexor sheath (open method). The wound is packed open, and is loosely approximated 
when the infection has subsided. Early and aggressive hand therapy is indicated for all cases.

 

 

 

 

 

 

 

 

6-  Deep space infection: there are 5 potential spaces between hand structures: 

  Thenar space:  
  Midpalmer space 
  Web space 
  dorsal subaponeurotic space 
  Hypothenar space 

 

 

 

 

 

 

 


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Of these the thenar and midpalmer space are clinically the most important. 

A penetration injury such as a splinter is often the inciting event in palmer space infection and 
S.auerus is the most common pathogen.

 

All present with swollen hand with losing of normal concavity on palmer aspect of hand and 
edema may extended to dorsal aspect of the hand giving appearance of  frog hand, very tender 
areas, restriction of movement with generalized symptoms like malaise, fever.

 

 

Treatment: antibiotics, elevation, hot soack. if no response, drainage of abscess according to 
site of infection, with special incision and irrigation.  

For midpalmar space preferred to do curve longitudinal incision in the palm with care to avoid 
injury to superficail palmar arch and digital vessels. 

 

For thenar space infection combined dorsal and volar incision , slightly curve longitudinal  
incision in dorsum of first web space, and separated incision on thenar eminence parallel to 
thenar crease. Care to avoid injury to palamr cutaneaous nerve and motor branch of median 
nerve

 

 

 

 


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7-  Bites: serious infection and subsequent loss of function can result from animals or human 

bites. Human bite is potentially serious because of virulence organism comprising human 
oral flora. Human saliva  may contained as many as 100 millon microorganism per 
milliliter, with over 42 species. S. aureus and Streptococcus viridans are the most 
common pathogens, also contained anaerobic bacteria e.g.  Bacteroides sp. and 
Eikenella corrodens. The most common mechanism is striking a tooth with a clenched 
fist.

 

The wound is most commonly over the metacarpophalangeal joints, putting the extensor 
mechanism and joint surfaces at risk of injury

 

Radiographs are mandatory, and may reveal a tooth fragment, fracture of the metacarpal

 

head, or air in the joint.. 

 

 

 

 

 

 

 

Treatment: 

All human bites to this region should be explored . The joint space should be irrigated and 
wound edges debrided. Human bite wounds should not be closed primarily, but in selected cases, 
large wounds may undergo secondary closure after 7 to 10 days of dressing changes and 
antibiotics. Eikenella corrodens is sensitive to penicillin and to clindamycine.

 

 

 

 

 

 

 

 

 


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Animal bites: cause by domestic dog and cat ,these wound tend to be less infected than human 
bite, but can cause substantial crush because of powerful jaw of dog. Cat bites are usually small 
puncture wounds because cat teeth are long and sharp. 

All animal bites should be thoroughly irrigated and joints explored when potentially violated. 
The majority of acute dog bite wounds may be loosely approximated after debriding the edges 
sharply.

 

 Cat bites rarely require closing, but may be if needed.

 

Antibiotic coverage for animal bites should cover the mixed flora found in animal saliva. This 
includes the gram-positive Staphylococcus and Streptococcus spp., anaerobes such as 
Bacteroides sp., and Pasteurella multocida, a small, gram-negative

 

coccus

 

 

8-  Viral infection: most commonly caused by herpes simplex virus and called herpetic 

whitlow and commonly seen in dental and medical personnel, and in children .usually 
presented with intense pain and erythema and small vesicular rash usually it self limited 
resolve in 3-4 weeks. 

The distinction from felon is made primarily from the history. Herpetic whitlow usually 
presents with a prodromal phase of 24 to 72 hours of burning pain prior to the development of 
skin changes
. This is followed by erythema and swelling, then the formation of clear vesicles. 
The vesicles may coalesce. The fluid within may become turbid, but not frankly purulent without 
bacterial superinfection. The pulp of the affected digit is not tense as in a felon.

 

The diagnosis may be confirmed by viral culture .

 

This process occurs over approximately 2 weeks and then resolves over the next 7 to 10 days.

 

Treatment: supportive care,acyclovir oral or intavenous.

 

Incision and drainage of a whitlow will invariably lead to a worse outcome than conservative 
management
..

 

  

 

#END of this Lecture …

 


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Hand Ex. & Inf.                                   Dr. Ahmed Khalaf 

 

4-10-2016

 

 

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