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Hand infection

Before the antibiotic era, infection was one of the commonest hand conditions requiring treatment. Although they are much less common now and can be effectively treated, they can still pose a serious threat to hand function, the usual reason for this being late or incorrect diagnosis, or infection with highly destructive or resistant organisms. Serious infections can spread rapidly through anatomical tissue planes in the hand, and if unchecked they can spread within the body and cause dangerous generalized infection, especially in immuno-compromised  people  or diabetics.

Minor hand infections are still quite common. Small abscesses around the margin of  the fingernail (paronychia) may settle rapidly on antibiotic treatment, but once pus has formed and failed to discharge spontaneously it needs to be let out, usually by pushing an instrument beneath the nail fold under anaesthesia appropriate for the age of the patient. Any pus removed is tested for the type of organism and its antibiotic sensitivity, and this information can become important if the infection is slow to settle.

Abscesses can occur in natural spaces within the soft tissue of the hand such as the fingertip pulp and various spaces in the palm of the hand. Most infections develop quickly with pain, swelling, redness and heat, making the diagnosis obvious. Some are much slower and less obvious, particularly with unusual organisms such as atypical mycobacteria (related to but not the same as TB) which can be caught from fish, tropical or wild, and are difficult to diagnose. They are treated by long term antituberculous therapy. They are not contagious to other people in the way that TB is. 

Infection within the flexor tendon sheath (tendon sheath infection) is particularly dangerous to hand function if not diagnosed early and treated effectively. Because the infection is tightly confined within the tendon sheath, there is early pain and rapid loss of movement of the affected finger, even before the more typical signs of infection are obvious. Although the infection is in the palmar side of the hand, swelling shows on the back of the hand where the skin is much looser, and there may be some redness on both sides. Passive straightening of the finger causes particular pain. Although antibiotic treatment can sometimes settle the infection if started very early, it is very important to proceed rapidly to surgical drainage of the tendon sheath. This can lead to complete healing and recovery of function, whereas untreated infection may destroy the tendon apparatus, with serious functional consequences. Furthermore the tendon sheath system can provide a pathway for extensive spread of infection, especially when the thumb or little finger are involved because these sheaths extend further.  Atypical mycobacterial infection (described above) may also affect the tendon sheath, producing large masses of thickened synovitis rather like rheumatoid arthritis.

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